Transforming the Environment in New York City to Reduce Chronic Disease November 18, 2013 Stella Yi, PhD MPH Research & Evaluation Unit Bureau of Chronic Disease Prevention and Tobacco Control New York City Department of Health and Mental Hygiene syi@health.nyc.gov

Presentation Outline Introduction Innovative Initiatives Active Design and Physical Activity Trans Fat Restriction Calorie Labeling National Salt Reduction Initiative Closing Remarks 4 examples of initiatives that have had national impact

The Epidemiologic Transition Over the last 100 to 150 years, both globally and in the United States we have been undergoing an epidemiologic transition. That is, a slow shift in the leading causes of death as life expectancy increases. This phenomenon is illustrated in the figure here, where the proportionate mortality of each disease is depicted from 1865 to 1990 and demonstrates that the leading causes of death 150 years ago were infectious or communicable, and over time chronic or non-communicable diseases have increasingly become the leading causes. Source: Vielrose E. Oxford, Pergamon Press Inc. 1965, Data for 1960-2000 from World Population Prospects, 1996 revision.

Life Expectancy at Birth, NYC and United States, 2001 to 2010 Source: Prepared Dec 11, 2012. Bureau of Vital Statistics, New York City Department of Health & Mental Hygiene; http://s3.documentcloud.org/documents/537407/life-expectancy-charts.pdf

Physical Activity Levels Among Adults in New York City and the U.S. NYC: 29% Both high and sufficient activity indicated meeting activity guidelines. Higher than national, but still far from the majority of residents meeting the PA guidelines. Accelerometer Data Source: Bartley et al. Epi Data Brief, Feb 2013. http://www.nyc.gov/html/doh/downloads/pdf/epi/databrief22.pdf

People Are Eating Out More Restaurant food is an increasingly important source of daily nutritional intake. Since the 1960s, the percent of food expenditures spent on foods eaten away from home has increased steadily. In 2006, away from home food purchases accounted for 48% of the American food dollar. Source: Food Consumption (Per Capita) Data System, USDA, Economic Research Service

Eating Out Is Associated with Obesity Calorie intake increasing – 200 calories/day from 1977 to 1996. Children consume 2X calories in restaurant meals compared to meals at home ~1/3 of our calorie intake comes from food prepared outside the home (770 vs. 420 calories) Sources: Guthrie et al. JNEB 2002; Zoumas-Morse et al. JADA 2001 7

Most Salt Intake in U.S. Adults Comes from Processed Foods 12% Processed foods 77% While eating 6% 80% of the salt consumption in the U.S. diet comes from processed foods. Thus reducing salt intake in a meaningful way means reducing sodium content in these foods. This chart shows us that there is great opportunity for the food industry to make small changes that could have an enormous impact. Given the evidence of the public health burden of cardiovascular disease, low physical activity and a challenging food environment, structural and policy changes to facilitate a healthier lifestyle are critical. 5% Mattes, RD. Donnelly D. Relative Contributions of Dietary Sodium Sources. Journal of American College Nutrition, 1991, 10:383-393. 8

Frieden’s Health Impact Pyramid: Modern Interpretation of the Geoffrey Rose Approach There has been demonstrated success for chronic disease prevention when it comes to individual level behavior change such as increasing physical activity, eating a healthier diet, or increasing adherence to medications. But individual behavior change is difficult. So as you know, in Frieden’s health impact pyramid, changing the context to make individuals’ default decisions healthier can have a higher population impact than clinical interventions or counseling and education. I’ll talk now about a few examples of how we have approached this, and how we have changed the built and food environments in New York City. Source: Frieden AJPH 2010

Active Design and Physical Activity

Fit City Conferences Active Design is: environmental design that encourages stair climbing, walking, bicycling, transit use and active recreation. Starting in 2006, the DOHMH together with the New York Chapter of the American Institute of Architects hosted a public conference to examine and debate the ways and means for increasing physical activity through design interventions. Every years since then, DOH and the AIA have convened architects, planners, landscape architects, designers, developers, public health professionals, government officials, and community activists, with the most recent conference, FitCity8, occurring this past June. 11 11 11

Active Design Guidelines Extraordinary collaboration between city agencies, AIA, private architects, academics and public health Download here: www.nyc.gov/adg Provides strategies for creating healthier buildings, streets, and urban spaces, based on the latest academic research and best practices These guidelines are the result of collaboration of 12 city agencies, the American Institute of Architects New York and members of the academic community – have been embraced both nationally and internationally.  An example of implementation in NYC includes the distribution of over 38,000 stair prompts to owners and managers of more than 1,000 buildings.  Evaluating this intervention has revealed that building occupants use the stairs more frequently when stair prompts are posted next to elevators and outside stairwells. These are publically available and may be downloaded from this website. DOWNLOAD COUNT Executive Order + Stair Bill TP’s (You don’t have to go into detail (sub bullets) on either, just wanted you to have it) Active Design Executive Order issued by Mayor Bloomberg on June 27, 2013, ensures that our buildings, streets, and neighborhoods will be designed to provide increased opportunities for daily physical activity by: Reviewing all new City projects for Active Design opportunities; Incorporating Active Design Strategies into general guidelines, standards and handbooks for construction and renovation projects; Ensuring the use of the LEED Credit for Health through Increased Physical Activity for applicable city projects;  Promoting Stairway Use in City-owned and City-leased buildings; Training City Agency design and construction personnel on active design strategies.   Two bills have been introduced to the New York City Council, which will amend the building code to promote stair use through access, signage and visibility measures.  There are two bills, although one is just an allowance. Public Access Stairway Bill Requires a continuous interior stairway that enables building occupants to access stairs to travel between floors; Requires signage to identify stairwell and prompt stair use; Requires fire-resistant glass to increase visibility of the stairwell. Hold-Open Device Allowance Permits the use of hold-open devices (i.e., magnets) on stairwell access doors in order to improve accessibility and visibility of stairways to tenants.

Trans Fat restriction Make distinction here between trans fat and calorie labeling regulation vs. NSRI being voluntary

Restricting Trans Fat in NYC Restaurants NYC was the first city to implement restriction of trans fat December 2006: Health Code amendment passed Phased in over 18 months Applied to all NYC restaurants and mobile vending commissaries In December 2006, a health code amendment was passed to restrict artificial trans fat in NYC restaurants. This restriction was phased in over 18 months, and applied to all NYC restaurants and mobile vending commissaries which numbers ~24,000. Source: Angell et al. Ann of Internal Medicine 2009

Impact of Trans Fat Reductions November 2008: Trans fat use had decreased from 50% to <2% June 2009: Decrease of 2.4 g of trans fat per purchase at NYC fast food restaurant November 2013: FDA announced proposal to reduce trans fat from the food supply On the basis of inspection reports, in November 2008 it was found that only 2% of restaurants were using artificial trans fat in oils, shortenings, and spreads, compared to 50% in 2005. A cross-sectional study that included purchase receipts matched to available nutritional information and brief surveys of adult lunchtime fast food chain customers, before and after implementation of the regulation demonstrated a significant decrease of 2.4 g of trans fat content per purchase. Following the NYC adoption of the trans fat restriction, 17 other localities nationwide followed suit. National activity – On Nov 7, 2013, the Food and Drug Administration announced a proposal to eliminate artificial trans fat from the national food supply. This is the culmination of work over the last decade. The activities at the DOHMH spurred national interest in trans fat and many foods have since had trans fat removed. Background notes: Part of the FDA's responsibility to the public is to ensure that food in the American food supply is safe. Therefore, due to the risks associated with consuming PHOs, FDA has issued a Federal Register notice with its preliminary determination that PHOs are no longer "generally recognized as safe," or GRAS, for short. If this preliminary determination is finalized, then PHOs would become food additives subject to premarket approval by FDA. Foods containing unapproved food additives are considered adulterated under U.S. law, meaning they cannot legally be sold. If FDA determines that PHOs are not GRAS, it could, in effect, mean the end of artificial, industrially-produced trans fat in foods, says Dennis M. Keefe, Ph.D., director of FDA's Office of Food Additive Safety. FDA is soliciting comments on how such an action would impact small businesses and how to ensure a smooth transition if a final determination is issued. Sources: Angell et al. Ann of Internal Medicine 2009; Angell et al. Ann of Internal Medicine 2012

Calorie Labeling

Enacting Calorie Labeling in NYC July 2008: Enforcement begins Restaurants that are part of chain with ≥15 locations nationwide required to post calorie information In July 2008, enforcement of calorie labeling began. Restaurants that are part of a chain with ≥15 locations nationwide were required to post calorie information – but could also include other information. The calorie information needed to be posted on menus, menu boards and item tabs in a font size that was the same size as the item name or larger, and adjacent to the item name or near the price. Subway Menu Board, 2007

Impact of Calorie Labeling October 2008: Calorie labeling did not decrease calories purchased overall Reductions in those who saw and used labeling Nationally calorie labeling will be required at restaurants with ≥20 locations In a receipt-based evaluation of the calorie labeling regulation in NYC, it was not found to decrease calories purchased overall, but reductions were observed in those who reported seeing and using the calorie information. One potential added impact effect of calorie labeling, may be increased demand for lower calorie options, and may also lead to chain restaurants offering more lower calorie options and/or reformulating existing products. At the time NYC’s regulation was introduced, it was the first of its kind in the country. Since then, similar laws have been passed in at least 19 other jurisdictions, some with additional requirements.  In 2010, as a part of the Affordable Care Act, Congress passed  a federal menu labeling law for chain restaurants with 20 or more outlets; final regulations from the FDA are still pending. Source: Dumanovsky et al. AJPH 2010

The National Salt Reduction Initiative

National Salt Reduction Initiative Strategy Decrease sodium content in foods by 25% over 5 years Decrease population sodium intake by 20% over 5 years Reduce risk of heart attack and stroke – the leading cause of death in US National Salt Reduction Initiative Strategy Set Targets: 2012 and 2014 target for packaged and restaurant food categories Invite Commitments: 28 food companies are committed to the NSRI Monitor changes: Changes in sodium in foods and in population intake using 24-hour urine collections The aim of the National Salt Reduction Initiative, or the NSRI, is to decrease sodium content in foods by 25% over five years, thereby reducing sodium intake and ultimately decreasing risk for heart attack and stroke. The NYC Health Department coordinates the NSRI, but it is a truly national effort. The NSRI partnership consists of over 95 state and local health agencies and organizations. Together, the partnership encourages food manufacturers and chain restaurants to voluntarily commit to NSRI targets. In terms of strategy, the first step was to set sodium targets for 2012 and 2014. Each of the 62 packaged categories and 25 restaurant food categories has its own set of targets. Next, food companies began to voluntarily commit to targets. 28 companies committed, representing a cross-section of the food industry. As a note, the targets are for sodium per 100g, as opposed to per serving, to establish a standard for analysis. When a company commits to the NSRI, they commit to a specific food category. The targets are not maximums, so a company can have some products above the target, as long as the sales-weighted mean sodium of their products is at or below the target. Measuring change by sales weighted mean is important because it encourages companies to reduce sodium in products that are driving sales and therefore consumed more – thus having the greatest public health impact. The final step in the NSRI strategy is monitoring changes in in sodium content in the food supply by analyzing the NSRI databases. This is an important component of the NSRI as it allows for evaluation and adds a level of transparency to the commitments.

Preliminary Results and Evaluation of the NSRI March 2011: Heart Follow-Up Study 2010 results release Baseline sodium intake in NYC adults using 24-hour urine collections (n=1656) Mean NYC adult intake is 3,150 mg sodium/day February 2013: 21 companies met their sodium targets While the full impact of this voluntary approach has not yet been evaluated – we do have some preliminary results to share.

Closing Remarks Chronic disease interventions that make the healthy choice the default choice may be implemented at the policy level. Cities can be the first step to implementing health initiatives and creating evaluation systems. Locally initiated health policies can benefit citizens nationwide. National interest and adoption of trans fat regulation and calorie labeling NSRI – national government was not acting, but a national approach was still created through a coalition of partners from across the country National/international interest in HFUS – chronic disease surveillance model