Health Disparities, in Los Angeles, the state of California, & the US

2. Health Disparities, in Los Angeles, the state of California, & the US Antronette (Toni) Yancey, MD, MPH Professor (7/1/07), Health Services Co-Director, Center to Eliminate Health Disparities

3. Staying healthy is easier for some than for others… UPPER SES LOWER SES Education College GED or HS Housing Own / Safe Rent / Safe? Physical activity Gyms /Parks, “move Parks?, “move insecure” secure” Neighborhood stores Fruit/Veg, food secure Drugs/Alcohol, food insecure Police Helpful Abusive Healthcare Private Doc ER, VA Sick leave Accrued None Leisure priority Exercise Rest Work conditions Safe, hi decis. lat., Hazardous, lo decis. lat., no +flex time no flex time Child care Nanny/hi-qual facil. Family/neighbor, lo-qual facil. Elder/disabled care HHW/hi-qual facil. Family/neighbor, lo-qual facil. Criminal just. sys. Little contact Much contact Premature M&M Low High

12. Years of Potential Life Lostby Ethnicity (per 100,000)

13. Years of Potential Life Lostby Ethnicity (per 100,000)

14. Death rates by cause for persons aged 45 to 65, 1995 Men Women Deaths per 100,000 persons Source: National Center for Health Statistics

15. Years of Potential Life Lost to Diabetes YPLL before age 75 y per100,000 population Age-adjusted, 1998 data Source: National Center for Health Statistics, Health US 2000, table 31

16. Black-White Mortality Ratios:Women in the U.S.

17. Age-Adjusted Prevalence of Overweight & Obese by Race – NHANES Adults Left bars = BMI 25.0 or higher; right bars = BMI 30.0 or higher

18. Adult Obesity: 1988-94 to 1999-2000 Race/Ethnicity 1988-94 Target Total White Female Male Black Female Male Mexican American Female Male 0 10 20 30 40 50 Percent Note: Data are for ages 20 years and over, age adjusted to the 2000 standard population. Obesity is defined as BMI >= 30.0. Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race. Source: National Health and Nutrition Examination Survey, NCHS, CDC. Obj. 19-2

19. Race / Ethnic Composition of the Los Angeles County Population, 1990 and 2000 1990 n= 8,863,164 2000 n=9,519,338 37.8% 44.6% 10.5% 9.5% 10.2% 0.7% 12.0% 40.8% 31.1% 2.8%

20. Los Angeles CountyService Planning Areas

21. Percentage of Adults (Age 18 years and older) living below 200% of Federal Poverty Level, by Service Planning Area, Los Angeles County, 1999 LA County 40% 1999-2000 Los Angeles County Health Survey Department of Health Services, Public Health

22. Percentage of Children (17 years old) Living in Poverty by Race/Ethnicity, Los Angeles County, 1999-2000 1999-2000 Los Angeles County Health Survey Department of Health Services, Public Health

23. Life Expectancy at Birth by Sex and Race/Ethnicity, Los Angeles County, 1998

24. Infant Mortality Rate by Mother’s Race/Ethnicity, Los Angeles County, 1991-2000

25. Trends in the Leading Causes of Death,Los Angeles County, 1991-2000 * 1998 rate

26. Prevalence of Obesity among LAC Adults by Ethnicity, 1997-2002

27. Physical Activity Levels, %L.A. County Adults, 1999

28. Physical Inactivity Levels:TV viewing/computer use, %L.A. County Adults, 1999

29. Physical Activity Levels:TV viewing>2 hrs/d vs. regular PA, %California adolescents, 2001

30. Prevalence of Overweight Among Children and Adolescents in the United States (NHANES)

31. Prevalence of Overweight Among Children in Grades 5, 7, and 9, Los Angeles County, 2001(California Physical Fitness Testing Program)

32. Percentage of Children (Age 3 to 17 years) Whose Parents Report Not Having a Park, Playground, or Other Safe Place They Can Get to Easily, by Household Income, Los Angeles County, 1999-2000 1999-2000 Los Angeles County Health Survey Department of Health Services, Public Health *Federal Poverty Level

33. Major Points • Significant reductions in mortality in the county population over the past decade. • Large disparities in health persist across racial/ethnic and socioeconomic groups. • Chronic non-infectious diseases and injuries comprise the predominant sources of morbidity and mortality; need to address underlying determinants. • Ongoing demographic shifts likely to shape future public health and health care needs.

34. Current Population Status • Little change in leisure time physical activity (PA) during past several decades of obesity increases (1 in 5), but marked increases in sedentary entertainment, transportation, and other ADLs (Sturm, 2004) • PA levels within increasingly sedentary, deconditioned, overweight population are unlikely to increase primarily through individual motivation and volition—relatively little demand for goods & services or political will to push for aggressive legislative policy change, e.g., radical alteration in the built environment favoring bicycle, pedestrian, and mass transit over private automobile transportation

36. Population benefit estimates of risk factor change: PA • 3-minute bouts of PA 10 times per day lowers serum triglycerides to same extent as 1 continuous 30-minute bout of PA (Miyashita et al., 2006) • Type 2 DM risk was 50% lower among individuals physically active at any level, and 66% lower among those at least moderately active (James et al., 1998) • Sedentary behaviors (e.g., TV watching) as well as sub-optimal >moderate PA levels contributed to DM & obesity risk over 6 yrs in women (Hu et al., 2003)

37. Population Obesity Control: Early stage in development To avoid exacerbating health risk/disease burden disparities, push strategies (skip-stop or slowed hydraulic elevators, proximal parking restrictions, non-discretionary time exercise breaks, walking meetings, mass transit & distant parking incentives) should be prioritized over pull strategies (building trails & parks, offering gym membership subsidies/discounts)—make it easier to do it than not to do it!

38. Lesser Effectiveness of Key Environmental Interventions in Underserved Groups: Example Posting of Signs Promoting Stair Usage (suburban Baltimore mall) • Overall, stair use increased from 4.8% to 6.9%, 7.2%, depending upon which of 2 signs used • Among whites, increased from 5.1% to 7.5%, 7.8% • Among blacks, changed from 4.1% to 3.4%, 5.0% • Among n’l wt, inc from 5.4% to 7.2%, 6.9% • Among overwt, inc from 3.8% to 6.3%, 7.8% Andersen, Franckowiak, Snyder et al., Ann Int Med, 1998;129:363-369.

39. Community “Cost-Sharing:”Policy Change Opportunities 1. Leveraging your managerial and fiscal roles to mandate or incentivize healthy/fit workplace practices for your subsidiaries, suppliers, community-based organizations (CBOs) to which you donate $, health plans with which you contract, etc. 2. Changing your internal organizational culture (social norms) to create healthy/fit organizational practices, in your social life and in your workplaces.

40. Community “Cost-Sharing” “Healthy/fit” organizational PA promotion practicesinclude core & elective components, e.g., 10’ movement (or walking) breaks in meetings/ functions & at certain time(s) of day; walking meetings; stair prompts & improvements; leading employee groups to stairs in moving between work activities; restricted near parking; distant parking & mass transit incentives; model & reward fidgeting and lifestyle PA integration (e.g., less high heel & tie wearing, more pedometer wearing, formal recognition/ kudos to those who walk/jog/swim during lunchtime)

41. Translating Evidence-Based CDC/ACSM Recommendation into Practice: Building on cultural assets Integrating 10-’ PA into organizational routine: • Movement to music integral to African-American, Latino culture—dancing normative for adults • Short bouts minimize perspiration, hairstyle disturbance • Social support & conformity desires drive participation (collectivist vs. indiv. orientation) • Addresses less activity conducive outdoor environments (safety, utility, aesthetics) • Designed for organizational settings for work, worship, other purposes--less disposable t, $

42. Lift Offs Work!: the Rapidly Growing Evidence Base • Documented individual and organizational receptivity to integrating PA on paid work time • Contribute meaningfully to daily accumulation of MVPA • Motivational “teachable moment” linking sedentariness to health status for inactive folks • Improvements in clinical outcomes from as little as one 10-min. break/day—BP, BMI, waist circ., mood, attention span, cumulative trauma disorders • “Spill-over” or generalization to inc. active leisure • Favorable cost-benefit ratio, eg, L.L. Bean mfg plant

44. Pausa para tu salud

45. WIC Staff Wellness Training

48. Community “Cost-Sharing” 3. Address K-12 PE deficiencies: • Require use of evidence-based curricula focusing on cooperation vs. competition, lifetime PA, maximizing MVPA/session, behavioral mgt (e.g., self-monitoring, goal set.) vs. motor skill dev. focus • Include in core curriculum, with same resources, monitoring & accountability as reading, math • Increase mandated t to 1 hr daily instruction K-12 • Require training in PE instruction in all undergraduate education curricula • Require elementary-level PE to be taught by certified PE specialists • Institute PE class size caps of <35

49. % PE class time in MVPA by % FRPL-eligibility & by district avg. Fitnessgram scores

50. Avg. amount of PE class time in MVPAby class size (secondary schools only) N=6 N=12 N=12 N=10 Class Size The amount of P.E. class time that students were physically active was less in larger classes.