- Hey, we're going to get started. We'll reward those people that actually got here on time. My name's
- Buff Brown, and I'm a member of BTOP. That stands for Bloomington Transportation Options for People.
- We've had a livable cities speaker series going on now for about, we're on our sixth year, and today
- we have our 18th speaker.
- Our VTOP is an organization that promotes walking, biking, and transit and promoting those. We actually
- work a lot with the city trying to encourage them to set policies that encourage those modes
- of transportation. This is also sponsored by
- A couple other groups, Health by Design is a group I want everybody to know about. It's how Gail and
- I met, an organization out of Indianapolis that also promotes health by focusing on the form of the
- city, urban form, and how that affects public health. And they're kind of, they're a local organization
- in Indianapolis, but yet I think they have a statewide reach as well.
- I hope that partners from all over Indiana join Health by Design and so they can collaborate. Also,
- I'd like to introduce Hannah Laughlin to tell you a little bit about a local group called GOAL, which
- stands for Get Onboard Active Living.
- Our speaker today is going to touch a little bit on childhood obesity. So I just wanted those of you
- who are in the audience who maybe don't know about our local efforts around childhood obesity to just
- hear a little bit more about that before we start. So the goal program, as Buff said, stands for Get
- On Board Active Living. And it's a free community-based childhood obesity program for not only children,
- but also their parents. And it's made possible by seven local community partners who give in-kind donation
- and staff time to be able to let us
- including IU Health Bloomington, the City of Bloomington Parks and Recreation, the Monroe County YMCA,
- Southern Indiana Pediatrics, MCCSE, RBB, and IU, both the Department of Kinesiology and the Office of
- Community Health Engagement. So our program is for children from the ages of six to 18 who are overweight
- or obese, and it's free, it's family-oriented, and it's community-focused. We try to get our kids out
- in the community to use the resources
- that we have here in Bloomington that can help them lose weight. And if anybody's interested in more
- information, my program team is here. Raise your hands so they can help answer questions if you have
- any at the end. Thank you. All right. Dr. Liu is a research scientist at the Children's Health Services
- Research Program in Indianapolis. He is an associate professor of
- clinical pediatrics at the IU School of Medicine. And so let me introduce Dr. Gil Lu. Thank you. Bye.
- So it's a real pleasure to be here talking with you today. And if you want to interrupt at any time,
- just do so. Yell out, hey, Gil, I have a question or a comment. I'd be delighted to make this a little bit more
- of a dialogue than just me lecturing to you. And let me see if I can get this to go. Okay, so I just
- wanted to start out by reviewing where the country stands in terms of rates of obesity. In actually
- the late 80s, the US Centers for Disease Control and Prevention, the CDC, decided they wanted to do
- nationwide surveillance of obesity rates and they thought a good way to do that was to get on the phone call
- randomly dial people in a representative sample and ask them many questions, two of which are how tall
- are you and how much do you weigh? So we know that there are biases in that type of question. If you're
- a woman and somebody asks you how much do you weigh, what do you typically do? You under report. And
- if you're a guy and somebody asks you how tall you are, what do guys typically do? They say that they're
- a little bit taller than they might measure.
- So anything that the CDC got they knew from the start that it was probably a very conservative and likely
- modest estimate. The first kind of complete data across the nation rolled in in 1995 and the color scheme
- is that if you are light blue then 5 to 10 percent or less of your adults had a BMI greater than 30.
- Are all of you familiar with body mass index, how that's calculated? Okay, so just to review.
- That's a way of adjusting your weight for your height, and it is a rough screen for whether you're carrying
- excess fat tissue on your body. So we know some people like, you know, who's Sylvester Stallone is,
- he's kind of built like a square, right? He's very, very muscular. He's kind of, you know, he's not
- the tallest guy. He's got a big BMI, but clearly he doesn't have obesity or overweight. So BMI has its
- limitations, but overall,
- It's a pretty good estimate for whether you are normal weight, overweight, or underweight, 1995. And
- this is the most current data from 2009. And you can see that essentially we've had to erase the blue
- color scheme and completely revise and change how we're looking at the rates of overweight.
- And in fact, most of the states in the US now have a rate of obesity greater than 30%, more than one
- out of every three adults has a BMI greater than 30. And actually, the one lone blue state is no longer
- blue. So Colorado used to have a rate of overweight that was less than 15%. But now, they join the rest
- of the country in having at least one out of every four adults having a BMI greater than 30.
- So my health times have changed. We've seen this literal epidemic and explosion in rates of obesity
- across our country. And this is sort of that same data but showing you the trend over time. So this
- is a line graph starting in the late 80s going up to, you know, close to current day. And there are
- some things to notice about this. One is that for,
- Overweight, which we define as a BMI between 25 and 30, that rate has stayed about the same. But we've
- seen most of the increases in people with BMI greater than 30 and in BMI greater than 40, which we define
- as morbidly obese and has very, very serious implications for health. So not only have we seen it happen
- across the country, but the severity of the rates seems to be increasing as well.
- So for kids, you can't very well call up a kid and ask them how tall they are and how much they weigh.
- It's just oftentimes they won't give you anywhere near a precise report. So what have we done instead?
- They've actually paid for vans to go out across the US and measure children and do other health data
- collection. And this shows that data for childhood obesity
- And in general, the message is that we've seen similar rapid rises in number of kids who are obese,
- a very clear trend of rise over time. And the perhaps most worrisome thing about this is do you see
- the orange line at the bottom? That not only are we seeing children become overweight, but toddlers
- and preschoolers are also seeming to become overweight more quickly. So Hannah, you've got to get
- programs for kids younger than six. Because if you wait that long, you're going to miss a very important
- window. OK, a little bit of trivia. Anybody know who started the National School Lunch Program? What
- president? Truman in 1946. And he said that it was important for schools to deliver lunches to safeguard
- the health and well-being
- of the nation's children, and also a measure of national security. So what had we been dealing with
- immediately before 1946? A war across the world. And interestingly, back in the 40s, the issue was not
- obesity, which is a concern for how well our soldiers are able to defend us now, but actually underweight,
- and particularly from Midwestern.
- recruits, they were showing up so malnourished that they were unfit to serve as soldiers for this country.
- So that was one of the main reasons why we started the school lunch program. And it might have times
- of change. It used to be that the witches had to worry about fattening the kids up first. But we live
- in an entirely different world now. So why do we worry about a BMI of 30? How did we pick this number?
- of 30 for body mass index. Well, it happens that we've been following people now long enough to where
- we can statistically determine that if your BMI exceeds 30 as a population, you are at much higher risk
- for terrible health outcomes. And I'll just highlight two of them for you, or a few. But one for adults
- came out in this paper in the Lancet just last year. And they looked at a million adults across 57 studies,
- a worldwide view.
- If you look, this paragraph I'm going to blow up for you, but moderate obesity, a BMI of 30 to 35 was
- associated with approximately three year loss of life compared to normal weight individuals. And if
- your BMI is greater than 40 in that morbid obese category, then you lose 10 years of life. And that's
- equivalent to smoking your whole life. So I don't know if, you know, how you feel about tobacco use
- or weight, but to me,
- the proposition of one-third of our population in this country looking potentially at a very significant
- shortening of their lifespan is something's got to change, right? And this is secondary stuff but I'm
- sure many of you have heard about the Affordable Health Care Act and the need to reform our health care
- expenditures, how much of our
- gross domestic product is using to support healthcare, clearly we know that in overweight individuals
- compared to normal weight that we spend much more on their care. So 41% more, $1.4 to every one for
- a normal weight individual. So it's also a heavy economic burden as well.
- For children, we don't know as much about the consequences of early overweight as far as how that's
- going to translate into lifelong health impact, but it's not a big stretch to say that it's probably
- just going to accrue more and more morbidity and mortality. But interestingly, we have seen that at
- younger and younger ages, we're seeing clinical conditions that used to be only associated with overweight
- in adults showing up in our children.
- So there is a study in the southern U.S. that looked at how many 5 to 10-year-olds who are overweight
- have elevated blood pressure, elevated cholesterol, are beginning to become resistant to insulin and
- have pre-diabetes. And half of those kids had one of these factors, a quarter had two or more. And that's
- something that we just really have no idea how that's going to play out.
- early and shocking and dangerous for kids to have. Findings like hypertension, hyperlipidemia, and insulin
- resistance at pre-adolescent ages. And then when you ask about health risk behaviors, children who are
- overweight report increased use of alcohol and tobacco, less exercise, lower school performance, more sadness,
- and lower quality relationships with their peers. So there's not just this clinical finding but also
- heavy psychosocial burden as well. So what might have changed over the past 30 years to lead to these
- rapid rises in obesity?
- Many people think that it's a combination of our genetic predisposition and a rapidly changing environment
- that's causing us to become more and more overweight. So just a diagram that in the past, well we know
- that you put fat on your body if your energy quotient Q exceeds your work quotient W. So just simply
- if you're eating more calories then you're burning in a day.
- Many people will convert that into fat tissue and just store it. That's how our genes were made. And
- that served us very, very well in the past when we were hunter-gatherers. So food was scarce. We had
- to work hard to get it. And we needed to store energy. And there's been hundreds and hundreds of years
- of environmental pressure to make us very thrifty in terms of our calories. And the thinking is in the
- past three decades,
- our environment has radically changed to where now we have a very, very easy time of getting lots of
- Q and we essentially have to do no W. So our world is such that we can consume calories very, very readily
- without hardly any work to get those. And you see that before our genotype, which was lean,
- and we had to conserve our energy is now showing up as the overweight phenotype, same genotype. So clearly
- our genes haven't changed in 30 years. It's unlikely that across the whole population something's mutated
- in our DNA, but much more likely that we're seeing the effects of a very different environment that's
- changed just over the past 30 or 40 years. So these are just, again, some lighthearted slides, but the
- biggest hamburger in the world is 11 pounds.
- And several people have taken it on. Eric didn't finish it. Kate did, unbelievably. And then I think
- one of the most worrisome things we see is how foods marketed to kids. So even though they call cereal
- mud and bugs, you can't see it because it's like brighted out. Kids buy the stuff. They love it. They
- demand it from their children. So there are all of these kind of dangerous social phenomenon going on.
- And we really have compartmentalized physical activity in our lives. So even the gems, we see escalators
- and people choosing the easier route to get there. And I love this timeline. It showed up in the Washington
- Post. And it started on my birthday, 1970. How many of you here are younger than 30? I'm just curious.
- Raise your hand. A large majority of you. And that's really cool. I'm really glad to be speaking to
- a young audience.
- In 1970, again, sorry that you can't see this, but the prevalence of child obesity was 4%, one-third
- to one-quarter of what it was now. And since I was born, there's been all of these amazing changes like
- HBO and the first VCR and personal computer. The Happy Meal came in at 1978, the 7-11 big gulp in the 80s.
- in where are some other like really neat things. I was trying to find somewhere on here like more and
- more women are working so more and more kids are having prepared food or less time eating together as
- a family. By the start of the 2000s, potatoes and white iceberg lettuce made up half of the vegetables
- that we eat. So we had a very, very narrowing of the diversity of our fruit and vegetable intake.
- And then at the beginning of this decade, we had to have things like Husky car seats. And Cookie Monster
- could only talk about cookies as a sometimes food. And then now, you know, we're really trying to backpedal
- and make up for all of these things that, you know, we thought were great. And they are great in some
- ways, but they're also affecting our health in a very adverse way.
- People have said it very eloquently. I'll read the middle and the last one. The current US environment
- is characterized by an essentially unlimited supply of convenient, inexpensive, palatable, energy-dense
- foods coupled with a lifestyle requiring negligible amounts of physical activity for subsistence. That's
- the world we live in today. And because of that, genes have loaded the gun. Hundreds of years have made
- us very, very thrifty in terms of hanging on to our calories and environment has pulled the trigger.
- And now we see one out of every three US adults overweight, one out of every five or six kids overweight,
- and children as young as two to five becoming overweight. The other thing, and I'll talk a little bit
- more, so diet is clearly a major piece of this. And I'm not going to talk as much about diet today.
- I'm going to lean more towards physical activity because that's my research interest. So forgive me
- for kind of setting aside
- but I'm going to focus more on physical activity and what we can do to design communities to promote
- physical activity. But if you look at what happens from late childhood to adolescence, physical activity
- basically steeply declines. And while physical activity is steadily decreasing from early adolescence
- to late adolescence, which is the x-axis of this chart,
- And girls, this is hours per week on the Y axis. We're seeing more and more computer use. And interestingly,
- TV is kind of leveled off in our generation. So we're still getting a lot of screen time, but it's moved
- from television to other electronics. And the same for boys, except even more so. Our young men are
- just really glued to some sort of electronic screen that is not TV.
- So this is for Hannah and the goal team. What do we know about weight loss programs? It's a big challenge.
- So if you really, really give people good counseling about aggressive lifestyle modifications, so really
- increasing their physical activity, teaching them how to eat a nutritious diet, we know that pretty
- reliably we can get people to lose 10 to 20% of their current body weight.
- But what we don't know is how to help them keep that weight off. So 80% of people who have been enrolled
- in good clinical trials of weight loss programs at the five-year mark have actually exceeded their starting
- weight. So we can get weight off in the short term. About 20% of your weight is a good goal and proven
- success in weight management programs. But very, very few programs know how to sustain weight loss.
- At five years, virtually all of them fail.
- And this is a complicated chart, but it's a way to represent a meta-analysis, which means to take all
- of the literature that exists that is strong evidence and represent it on a page or several pages. And
- this just shows the current state of child weight management programs. So the first thing I want to
- point out is that you can fit all of the evidence on one page. That's kind of sad. So we've got a long
- way to go to figure out how to help kids manage their weight.
- And this line right here, if you touch this line, your trial is no different experimental group versus
- control. So anything touching this line showed no significant effect. So you can see most of the studies
- are touching the line. Only a few are showing statistically significant weight management and there
- are one, two, three, four, five trials right now out of all of the published literature that shows that we can,
- effectively get kids to lose weight in weight management programs. And they have very, very modest effects.
- So in general, the kids drop between four and eight pounds in the program after six to 12 months. None
- of them enroll kids that are preschool age. So that's a wide open frontier for research. And we don't
- know whether it benefits like their lipid status or their blood pressure or their insulin sensitivity.
- And there is some evidence for older kids that some of the weight loss medications work, but again not
- for long term and actually many of these have bad side effects. So we have no idea once a child or a
- person becomes overweight how to help them in the long term. That's kind of the overall summary of this.
- So I'm really like giving you such depressing news. The world is becoming more and more overweight.
- That overweight has horrible health consequences and once a person is overweight there's very little
- return to normal weight for those people who have been enrolled in good trials that have collected data
- in the long term. So what does that hold for us as far as priorities? I would suggest that instead of
- focusing on treatment, while it's important and should receive continued research, especially for kids,
- we need to look at prevention. Because it seems like treatment is not the answer, at least at the current
- state of things. OK.
- More trivial pursuit, which of these household appliances is least used by immigrant families in the
- US? Anybody want to take a stab at it? It actually is the dishwasher. Anybody here grow up in an immigrant
- family? I can't really tell people's race, ethnicity. I did, my parents moved here from the,
- from China and Taiwan in the late 60s and they sure enough use their dishwasher as a drying rack. They
- just don't believe it gets dishes as clean as they can and they think it's a total waste of like water
- and electricity. Why do I ask you that? Well, the person who invented the front loading dishwasher is
- from Indiana, his name is Sam
- Regenstrief and any house that has a front loading dishwasher pays a little bit on Sam's patent. So
- you can imagine the Regenstrief family has just accumulated a fair amount of wealth and he's done very,
- very good things with that money. One is that he's given it to the Boys and Girls Clubs of America which
- is a great youth community organization. But the other is that he established where I work which is
- the Regenstrief Institute at Indiana University in Indianapolis.
- And another thing that Sam had great foresight to do is he said, why don't we go ahead and start working
- on electronic medical records at the Regan Street Institute. That's one of the things I want for this
- place to be a leader in. So Indiana has one of the longest standing, largest electronic medical records
- in the world, which I think is really, really cool because it's a great tool for research.
- So we have data on over 6 million patients. They've generated almost, you know, 900 plus million observations
- and it's widespread. It's the nation's only city-wide medical record and it's rapidly becoming state-wide
- in terms of getting disparate hospital systems to share data and store it so that people can look at
- it and study it.
- So I want to show you some analyses that we've done. We went into the record and asked for all heights
- and weights on kids from 4 to 16, from 96 to present. And then we looked at whether or not they were
- seen for well child visits versus sick visits. And then we categorized them in terms of their weight.
- So we take care of about 10,000 patients a year. Many of them come for multiple visits, but many of
- them only come one time.
- We have a mostly publicly insured population, so they're fairly transient. And this just shows you that
- they're normally distributed. So it's half boy, half girl, mostly younger, which is when kids come to
- the pediatrician more. But you can see that half of our population is African-American, and over half have
- either Medicaid or Medicare. So it's a low income, high minority population living in Indianapolis,
- basically who I'm talking about. So one of the limitations of this work is I don't have a lot to say
- about wealthy, non-minority subjects at present. We're trying to get that data in so as the record grows,
- we'll have more of that population. And just like the national data, we've seen our obesity rates steadily
- climb over time.
- And this is interesting to me. So one thing that you can see is that our Latino subjects have the highest
- rates of overweight. They're the collection of bars in the middle and that they're becoming overweight
- at much younger ages. So we know that, you know, toddlers and preschoolers are rapidly becoming overweight
- and especially among Hispanics and especially among Hispanic males. They seem to be at really, really
- high risk for developing overweight.
- early and then staying overweight throughout their childhood. And that's just shown here. It's very,
- very hard to see, but this is a model that's virtually invisible. Age is on the bottom and rate of overweight
- is on the top. And this just shows numbers of kids becoming overweight by a certain age. And you can't
- see it, but this is the Latino curve. It's earlier than everybody else.
- So at age 4, we saw about 15 to 20% of our Latinos already crossing a BMI threshold that would define
- them as obese. So that population in particular deserves some attention. So America's losing the battle
- against obesity. Sustainable weight loss has not been demonstrated. In Indianapolis, we see
- clear patterns by race, ethnicity, and sex. And based on these things, we probably need to start working
- on obesity as early as we can, like even with pregnant mothers before the child pops out of the womb.
- Any questions? You guys hanging in there? OK, I see a couple in the back. Why don't we take two questions
- that I'm going to motor on.
- I think that's a very good hypothesis. I don't know of any specific literature that talks about stay
- at home moms versus working moms. I do know that there have been many studies that show the more that
- children eat breakfast at home and dinner at home, the healthier their diet composition is and the less
- risk they have for overweight. So I think that connects. And then there was one other question.
- Very, very good question. So it turns out that African American females have the next highest risk.
- So it actually goes Hispanic males, African American females, Hispanic females, and then the rest are
- pretty close. And one piece of good news that I didn't mention is it looks like recently our rates of
- overweight have leveled off.
- You know, so cause for, you know, a little bit of celebration there. But for certain subgroups,
- the Latinos, maybe it's still rapidly climbing. So that's a great question. Okay, this gets to my second
- half of the talk. And so now in terms of prevention, there are many ways to go about that. Policy approaches.
- But I'm going to focus on something called the built environment. And that just means anything that
- man decides to install in their communities. And I'm really looking at kind of larger scale features.
- So while it could be, you know, stairs and signs and buildings, we're going to talk about ways that
- we decide how to allocate land use to residential versus commercial landscaping that we do in street design.
- are the features of the built environment that I'm going to be talking more about. So it seems pretty
- clear that if we look at how we do our transportation infrastructure, how we decide to allocate our
- land use mix, and how densely we develop residential areas, those things have been proven to promote
- walking and biking in adults. So if you take a street network that is more
- a grid structure versus the cul-de-sacs and disconnected streets that we see in suburbs, then people
- walk and bike more on a grid. Similarly, if you take residential commercial retail and you blend it
- all together like you see in the middle of cities, so people living in apartments that are close to
- stores and also close to where they work, adults walk and bike more. And then lastly, in places where
- there are more and more adults living,
- densely in an area, that is also promoting a physically active lifestyle. And that probably makes sense
- to a lot of you. So we're looking for the best ways that we can modify the built environment to increase
- physical activity, to enhance a person's nutrition in their diet, and to keep them from being sedentary.
- And we don't know how to do that for kids.
- quite yet. So how many of you grew up on a cul-de-sac or a separated street? Yeah, yeah, many of you
- did. It's a great place for a kid to be, right? It's safe, it's away from traffic, the parents can more
- easily supervise what's going on, maybe you knew your neighbors more.
- But urban designers who are looking for smart designs for adults hate cul-de-sac. So you can see there's
- this kind of battle already set up for what do we do in terms of good things for kids? What do we do
- in terms of good things for adults when the two things are so separate and distinct? Hard to say. What
- we do know is that the more that you get a kid outdoors, the more active they are, which is
- a neat association. And that we need more research into this area is kind of the summary of this slide.
- And I have a particular interest in greenness. So the way that we landscape cities with more and more
- vegetation and seeing if that improves health. And that's based on lots of kind of interesting studies.
- So let me just holly a couple for you. One was just looking at people who were hospitalized that had
- the bed by the window or the bed that didn't have the view. And it turns out that the patients who could
- look out onto a green setting requested pain medication less.
- Their nurses thought that they recovered better and they actually had an earlier discharge from their
- hospital. And that, you know, hard to say exactly what's going on there, but I thought, and it's one
- of the earlier starts at looking at the effect of greenness on health. And now we're seeing more and
- more in studies that communal green spaces build a lot of community cohesion and good social interactions.
- So gardens and parks are great places for neighbors to get to know each other. And I wanted to look
- at how these spaces,
- can get kids to be more active and to have less obesity. So, like I said before, we took all the patients
- in our county out of our medical record system and we started mapping them as a start to look at what
- their environments were like. And on this map, the purple dots is color coded by race and green is
- Caucasian, purple is African-American, so what would you say about Indianapolis? Very segregated, right?
- It's like oil and water along north-south boundaries. So that's the first thing that's just like, wow,
- I didn't realize that blacks and whites are living so separately in our city, and they probably have
- very distinct environments as a result of that. Next, we...
- Anybody a geography major in here? Or doing any geographic information, spatial analysis stuff? I'm
- not one of those people, but there's a way where you can look at observations in space and look and
- see whether they're clustered. So we just wanted to know are overweight children clustering in our city?
- And it turns out that they are. And especially when you look separately by race, the African American
- children who are overweight are living
- near other overweight kids. So again, another piece of evidence that suggests there's some
- sort of environmental factor going on that's affecting kids' weight. OK. So we decided, well, let's
- actually see if we can get at the greenness question. So we looked at the kids who are staying in our
- hospital system so we can measure their weights over time. So it's better to have longitudinal data
- versus a snapshot.
- Let's look at the effect of greenness and residential density on their change of weight and BMI. And
- this just says both greenness and residential density and individual level factors affect a person's
- weight and that these two factors probably interact in some way. So that's our conceptual model. Let's
- get into kind
- detail, but anyway, we also included the age of the child, their race, whether they're boys or girls,
- their starting weight, so whether they were overweight or normal weight at the beginning of the study,
- how they were insured, the income level of their neighborhood based on the census, so sometimes poor
- kids live in wealthier neighborhoods, sometimes poor kids live in poor neighborhoods, and the year,
- because we know that obesity rates are climbing over time.
- So how did we get at greenness? Well, it turns out that all the time satellites are flying over the
- US and one of the things that they're collecting is information on vegetation. And so they take a picture
- of the surface and by looking at two spectrums of light, the visible spectrum and the infrared spectrum,
- you can actually determine how much plant matter there is and whether it's healthy or not.
- It's just really useful for us. And that's called the Normalized Difference Vegetation Index, NDVI.
- So we've got greenness in hand. And the scale goes from minus one to plus one. So if you're less than
- 0.1, you're in a pretty non-vegetated place. And if you're from a half to one, you're in very, very
- lush surroundings, a park or
- Here it'd be like rainforest kind of. And then the city in Indianapolis collects data on every parcel
- because they want to know how to tax. So for every little piece of land with a structure on it, Indianapolis
- and I'm sure Bloomington too knows whether it's residential, commercial, industrial and then they use
- that to collect funding, public funding.
- land use as well. And then we took patients' homes and drew circles on them and said, tell me what the
- NDVI is in the circle and what kinds of land use there are in the circle. And it turns out that there's
- a bunch of good variation
- in greenness across our city. So there were some places like parking garage or the core of our city
- or industrial complexes where the NDVI was very, very low and there were people living near those places.
- And then there were places like parks or cemeteries where it was super green and similarly there were
- plenty of families and everything in between. In this study we had roughly 4,000 subjects.
- We saw the same pattern as our general clinic population, so mostly younger than 10 years, a high rate
- of publicly insured, a high rate of obesity, and many of them were living in low income neighborhoods.
- So the average income of the neighborhood that a child lived in was 37,000, just to give you an idea.
- Basically what we saw is that the higher the NDVI, the lower the rate of weight gain over time. So for
- these thousands of kids in the urban location of Indianapolis, greenness was protective against obesity.
- Now it's hard for us to say exactly, you know, does greenness cause lower weight over time? In order
- to do that, we'd have to conduct an experiment.
- But this is pretty good preliminary evidence that landscaping may be an approach to get kids more active
- and to protect them from gaining excess weight. So higher greenness was associated with either declines
- or lower rates of change in BMI. Residential density was less important in this group than we've seen
- for adults. And we also looked at things like the street networks and they weren't very important for kids.
- So. And this is one of the largest studies of its kind. It has lots of racial representation of minority
- groups, which is also rare. And I had the lecture of working with geographers and urban planners to
- set up the study. So those are some of the strengths. Why might greenness be a good thing for kids?
- Again, the more time kids spend outside, we know the more active that they are.
- In cities, it turns out that the greener a neighborhood is, the more it seems like people are caring
- for their neighborhood. So if you're putting in the time to landscape an area, then there's likely more
- social investment in that neighborhood. And we've seen through other studies that greenness produces
- beneficial effects in terms of reducing stress, people reporting higher quality mental health, and higher
- self-esteem as well. So we're going forward to look
- at this more, and let me tell you briefly about that. So I'm going to go by these real quick. The next
- thing we want to do, so we have the measures from the clinical record, we have the observations of the
- urban form, but what we didn't know is whether kids were using the greenness or not, right? So we have
- these big kind of gaps in the study. So how are we going to figure that out? We are going to give kids
- GPS enabled cell phones,
- and strap these little pager-like devices on them called accelerometers which measure all of your activity
- over time. And they hold charges for a month so you don't have to recharge them. So we're going to directly
- observe where kids go, where they accrue physical activity, and then we're going to also ask them in
- interviews, tell me about the exercise that you're getting over the week, how you're using the places
- near your home. And with this technology,
- This is an example of a path of a person wearing the cell phone over time. So time is from early in
- the day to later in the day rising. And then you can see the places where they go. And if you connect
- the path data with the accelerometer data, oh, this is a bunch of kids. And then you can see places
- where activity is elevated, which would be the peaks on the map, and where it's low, which are
- flat areas of the map. So hopefully we'll get more at the missing behavioral measures, which we can't
- get just by like extracting things from the medical record. And forgive me, but I'm going to blow by
- these. We're also working with the public schools in Indianapolis to improve their physical education.
- That's how we're delivering the GPS units and accelerometers. So I'm just going to go by this.
- Ultimately, the way that I would love for this research to be applied is by the policy makers who actually
- are designing the neighborhoods and incentivizing development. So one great thing we're seeing
- in Indianapolis is a rapid expansion of urban trails, which has had a lot of benefits. Raising property
- values, bringing amenities to low-income neighborhoods versus the urban sprawl
- that we've seen in many places. And a lot more urban gardens in our city. And we've got a lot of work
- to do. So in Indianapolis, we have much less parks than similarly sized cities in the US. We have very,
- very low rates of public transportation and walking and biking.
- If you look at the public infrastructure, the built environment that we have to support physical activity,
- especially in terms of sidewalks, very low. So many, many opportunities for intervening. And I'll conclude
- by just saying, you know, this work was supported by the National Institutes of Health and had a lot
- of great partnerships. Geography, School of Public and Environmental Affairs, the Polis Center, which
- is an urban research group,
- and the biostatisticians to run the analyses. So thank you very much. I'd love to hear questions or
- talk more with you about your ideas for how to prevent obesity through communities. So that's it. Questions
- anybody? Go ahead.
- Yeah, we're just starting that right now. Okay, so the question was I think related to the last few
- slides given that we have the path data and the direct measurement of physical activity have we included
- greenness as a part of analyzing that data and we just got
- those observations from the schools a few months ago. So we are. We're going to look at, you know, one
- of the hard things is you have this path and the GPS device can update itself every five seconds is
- what we've set it to. And then you have a minute by minute measure of their activity. So we're buried
- in data. And we've got to boil it down to destinations versus the, you know,
- commuting from destination to destination and then figuring out how important is it when you're moving
- by car from one place to another or if you're in your house versus your friend's house. So we're still
- struggling with how to take that path, boil it down into a variable and then look at greenness for that.
- So we could take the greenness over the whole path but I think we should wait it by time spent in a
- place and then even when you're spending time in a place what activity
- you're doing. So there's still some steps we're taking to transform the data into something that we
- can plug into a stats package.
- Yeah, so I'm not 100% sure where the public transit. Yeah, thanks, thanks, thanks. The question was,
- given that Indianapolis has either passed a new public transportation act, I actually think they're
- still in the middle of passing it. How might improvements in public transit be relevant to this type
- of research into preventing obesity? So I think that that's still unclear.
- that we don't know about Indiana is just how to get people on the public transit. And I don't know if
- that's a question of there's so little good public transit that people just discount it as an option
- or if we had a bunch of buses running all the time if people would get on them and use them. What I
- do know is that for our patients, low income families who are race, ethnicity, minorities, they don't
- have access to,
- public places for fiscal activity. So often parks are removed from their neighborhoods and places to
- buy fresh fruit and vegetables are removed. So they need some way of getting from where they live to
- an amenity for health. And most of them rely on public transportation. So I think that it would help
- but I don't know of any studies I can cite that would tell that.
- Charlotte, and they studied the people that stopped driving and started riding the transit. And I think
- there was an average loss of about seven pounds. But it's a study that's substantial. And also the amount
- of walking that occurs from transit, for transit riders, people have found that to be around 20 to 30
- minutes of walking.
- per day, which wouldn't otherwise have existed.
- Yeah, yeah. So the question is in Bloomington it seems like you have plenty of options but people are
- either unaware of them or even if they're unaware they might have other barriers to accessing them.
- So I think there's a lot of great research going on right now in terms of social media and marketing.
- to help people because clearly what we've seen although it's probably becoming less is one, people were
- unaware of the problem of overweight. So at an individual level many people at BMI of 25 to 30 actually
- don't think that they're carrying too much weight when we can show that over a lifetime that weight
- will cause their health to decline. So that's one is just perception of weight status and being,
- activated to change your lifestyle. The second question of if you want to change your lifestyle but
- you don't know how to use the things in your environment is a big challenge. So I can say there's many
- instances of healthcare providers telling people that they need to lose weight, exercise more,
- and eat better, but they are completely unaware of all of the environmental barriers that people face
- when they do that and that's
- True for everybody but especially so for families that have low income or come from a different cultural
- background than their provider. So I think that there needs to be like a multi-pronged approach to addressing
- this and people will hold up as an example what we've done with tobacco. So physicians have learned
- to counsel better about tobacco use.
- The policies about taxing tobacco, the availability of tobacco, and then the perception of tobacco in
- media has been changed. And we've actually seen tobacco use decline by a lot over time. It's been actually
- a very successful public health intervention. For obesity, the hard thing is it's not just one behavior,
- not whether you're lighting up a cigarette or not, but it's what you eat, how you move, and then
- Not only how you move, but how you keep from sitting still. So sedentary activity is separate from physical
- activity, and both of them have to be addressed. So I think the tough thing is telling people where
- their markets are, where they can exercise, what they should do at home, how they parent, all those
- things. Really, really complicated interplay of behavior that produces this health condition of carrying
- too much weight. Yeah, maybe a couple more.
- Yeah, so the question is what is there about best practices or evidence for preventing obesity in toddlers
- and preschool kids or managing obesity? And I'll just say right now it's an open question with active
- studies underway and everything that's been reported is preliminary. So there are piloting programs,
- one just to show that we can safely talk about like reducing caloric intake.
- for a toddler and helping toddlers choose better foods to eat. We really don't know how to do that.
- We know more about, you know, in terms of activity, if you want a toddler to be active, then it has
- to be things like play instead of exercise. And you're right about the mothers are just as important
- or perhaps more important than the child. So for toddlers, certainly, they're a product of their environment.
- They're making very few or essentially no independent decisions.
- intervene on the guardians that are providing their care. I think that's part of the problem. I would
- actually argue again for families that have low income and live in very distressed cities, even if they
- know the right things to do, often they have a hard time achieving those things. So one thing I hear all
- the time is, I really would love for my kid to be active. I would love to be outside. That's the way
- I grew up. But where I live, they have to stay in the house. And that's just what I have to do to keep
- them safe. So I don't know. I think it's also creating supportive environments that currently don't
- exist, as well as educating and enabling families and individuals to change their behavior.
- Okay, I'll take one more and then maybe I'll talk with you individually. So go ahead.
- we can do this, we really could, we just have to decide that we...
- I think that's a great closing comment. So again, thank you so much for taking time out of your day
- to come and attend this talk and I'll stick around and if anybody has any other questions I'd love to
- speak with you individually.