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.