Healthy behaviors and where the money goes

Via Ezra Klein, here's a striking infographic from the Bipartisan Policy Center comparing what makes us healthy to how we as a nation spend our health dollars:

Infographic from the Bipartisan Policy Center

Infographic from the Bipartisan Policy Center

As it illustrates, behaviors are major contributors to our health status, but a tiny fraction of US health spending goes to encouraging healthy behaviors like physical activity.

The Bipartisan Policy Center report Lots to Lose: How America's Health and Obesity Crisis Threatens our Economic Future offers several recommendations for improving nutrition and physical activity in the US. In addition to recommendations for schools and childcare providers (start encouraging physical activity at an early age, and require 60 minutes of physical activity during each school day), it has several recommendations for communities. One acknowledges that local government funds are tight, but suggests partnerships to increase the use of limited spaces for play and exercise:

In communities that lack safe, adequate places for children, youth and adults to exercise and play, or where schools don't have the facilities to support physical activity programs, "joint use" agreements provide a mechanism to enable the shared use of public facilities. Typically, this type of agreement would be struck between two government entities, such as a school district and a city or county. Joint use agreements have been successfully used in a number of locales to expand the sport and recreational opportunities available to students and members of the community. A variety of other low-cost options and public-private partnerships have also been used to promote healthy activity at the community level -- a good example are the various walking initiatives, such as Everybody Walk and Get Fit, that have been launched in neighborhoods and at schools across America.

And there's this recommendation, which will sound familiar to people in public health:

Healthy Communities Recommendation #8: Local governments should use the planning process to change the built environment in ways that promote active living.
Growing numbers of cities and towns are using the planning process and zoning codes to shape the built environment in ways that promote walking and bicycling, help residents stay connected, and improve quality of life. In many cases, mayors and county and city council representatives are working with architects and designers and with planning, transportation and public health departments to create healthier buildings, streets, and urban spaces based on the latest academic research and best practices. As an alternative to imposing new requirements, some cities have removed or changed old zoning codes that work against the goal of encouraging healthier, more active living. Other cities have incorporated physical activity guidelines into their construction codes and adopted policies that support outdoor play and exercise. These include offering incentives to designers and developers to build in ways that encourage walking, bicycling, and active transportation and recreation.

I've seen a lot of this going on in DC over the past few years. As the city has torn up our streets to upgrade water and sewer lines, they've rebuilt them with better sidewalks and new bike lanes. And Christine Green at Greater Greater Washington describes some of the community initiatives in the DC metro area:

Prince George's County is taking action through a partnership of towns within the county. The Port Towns Community Health Partnership has a policy development team focused specifically on the built environment and nutrition policy to improve options for active living and healthy eating.

The group, which includes the towns of Bladensburg, Colmar Manor, Cottage City, and Edmonston, included a community health and wellness section in the Port Towns sector plan with the goals of providing safe places to walk and exercise and access to nutritious foods. The group is following through on sector plan recommendations to formalize a wellness opportunity zone as part of the zoning code. This would include changes in the built environment, access to healthier foods, and improved environmental stewardship.

Across the Potomac, the Fairfax County Health Department established the Partnership for a Healthier Fairfax, a group of community members and organizations concerned with public health. The Partnership created an environment and infrastructure strategic issues team as one of five teams who will make recommendations for improving health in Fairfax County. The first focus is a on local policy. The team is doing a scan of policies, including transportation and land use, that could be modified to promote a healthier and safer physical environment.

When planning is done poorly, without sufficient consideration for active transportation and exercise opportunities, the consequences can be particularly severe for those who have few other options. In a "Narrative Matters" piece in the journal Health Affairs, doctor Cameron Page writes about one of his patients whose health suffered after his community lost park space for pickup soccer games.

P, a Hispanic man in his early 40s, told Dr. Page that for years he'd been in the habit of playing pickup soccer games at Macombs Dam Park in the Bronx. But construction of the new Yankee Stadium resulted in the loss of that space. The city had pledged to replace every acre of lost parkland, but Dr. Page learned that it classified a brick walkway and a parking garage topped with artificial turf as parkland, and moved the remainder of the park half a mile away on the other side of a pedestrian-unfriendly expressway. The new park had tennis courts and bricks, but no grass on which to play soccer.

For P, the loss of the soccer field meant worse health. He gained 40 pounds and his back started hurting. Page writes:

We tried to come up with an alternative exercise plan, but P loved soccer. After a few wasted minutes discussing Zumba and Pilates, I gave up. I told him to try to find another soccer field or start walking to work.

...In the summer of 2010, when I finished my medical residency and said goodbye to P, there was still no place for him to play soccer. He was still forty pounds overweight, he’d developed hypertension, and his LDL (the measure of so-called bad cholesterol) had increased from a well-controlled 100 to a troubling 160.

... P isn’t playing soccer in the shadow of Yankee Stadium anymore. He might not be playing soccer at all. And there’s not much I can do about that; I can’t write a prescription that gives him access to a local park. The challenge of the obesity epidemic extends beyond the doctor’s office to urban planners, city council members, and—in a democracy like ours—all of us as citizens. In a sense, when it comes to protecting green space, we are all each other’s doctors.

It does take resources (financial and otherwise) to ensure that communities have sidewalks, bike lanes, parks, and other elements that make it easy for residents to engage in regular physical activity. Relatively small investments can yield impressive activity improvements, though. If we could channel a small fraction of our $2.6 trillion in annual national healthcare spending into improving the built environment, it could do a lot to improve our overall health and quality of life.

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