Solving the Public Health Crisis with Smarter City Planning

I want to talk about some of the threats to our children's health and how we can put them on a course of health and well-being. I'm going to talk about how this relates to schools-how we design our schools, where we put our schools.

When I was a young doctor, we spent 7 percent of the gross domestic product of the United States on health care. It's now twice that ratio. In fact, we spend about 2 percent of all the money in America on diabetes; about 11 percent of all expenditure on health care goes to diabetes alone.

There's only one fact that 90 percent of Americans agree on, and it is that Americans are too fat. I'm going to talk about this and how it relates to health and well-being. In 1990, less than 10 percent of Californians were obese. In 1997, 15–19 percent of us were obese. By 2004 over a quarter of the people in some states were obese; in California, it was about 20–25 percent. Not just overweight, but obese. We'd love to have 15 percent of California's children exceeding the 95th percentile of their SATs or some other category, but for their weight-to-height ratio, 15 percent are over the 95 percentile of what is considered a healthy weight-to-height ratio....

That's important because once you're obese as a pre-schooler, there's a good chance you'll be obese as an adult.... In the school-age category, 22 percent of kids exceed the 95th percentile; about half of school-age kids end up struggling with it for the rest of their lives. These patterns that are set up early have huge implications.

The most rapidly growing surgery in America is bariatric surgery-stomach stapling. It costs about $30,000. The insurance industry is scared to death of the costs of this surgery, which has increased from 5,000 procedures per year to 15,000 per year in a short period of time. The costs are enormous, particularly in the medical care system, which is already absorbing 15–16 percent of the wealth of America.

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Being overweight is bad for us. It raises our risk of stroke, heart disease, gall bladder disease, joint disease, but one of the things we worry about most is diabetes. If you're obese, men are 11 times more likely to become diabetic, and women are 40 times more likely.

In 1993–94, 6–8 percent of Californians had diabetes. By 1999 8–10 percent had diabetes, and by 2001 the rate was over 10 percent. If you walk down the street in Los Angeles, one person in ten has a disease that will cost them their retinas, their kidneys, and eventually their lives. When I was a young doctor, the fifth most common reason for people needing donated kidneys was diabetes. It's now far and away the number-one reason. The average 11-year-old in America is 11 pounds heavier than in 1980.

I did this presentation for Governor Schwarzenegger's office, and when I interviewed for the job they asked me what my priorities would be. The first was preparedness, the second would be the obesity epidemic, the third would be the need for a Department of Public Health-and I am delighted that Los Angeles has taken that lead, which has an excellent health officer in Dr. Fielding.

The governor's folks said, "Obesity? Why are you so concerned about this?" But I told them that one-third of all the little kids in schools will be diabetic in their lifetime if the trends we are looking at continue. The average loss of life is about 15 years, and there is an average reduction in quality of life by about 20 years....

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Where did this epidemic come from? We eat too much, and we don't burn enough. We eat like lumberjacks and work like bankers. Fast food hamburgers are wonderful short-term economic decisions; you can get almost a days' worth of calories for a couple bucks. They're not good long-term health decisions. And we've changed the diet of our kids; now kids are drinking Big Gulps, with 250 calories of sugar. You can burn it off; you can play basketball for 40 minutes to burn off that one soda.

How important is exercise? A study of 100,000 nurses over 25 years kept track of how many of those nurses died every year. The thin nurses who stayed active were a standardized death rate of "one;" the ones who became obese had a 95 percent higher death rate. The nurses who became unfit had a 60 percent increase in death rate, and unfit and obese was a 2.5 times increase in the death rate. Being obese and not exercising enough is a matter of life or death.

So when the schools say that physical education is not important, it's actually a matter of life or death. There is no drug that confers as many benefits as physical exercise. In fact, if the drug companies could come up with something that would improve your life span, lower your blood pressure, make you better looking, improve your sex life, and save you money they'd charge you $10 a day for it. Exercise will do all of these things....

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I'm going to argue in part that childhood obesity is because of the inability of children to walk to school. Nothing in America has gone down except the number of schools-70 percent since World War II. Schools have gotten bigger, and the number of kids who walk to school has decreased. In 1969 half the kids walked to school; now it's less than 15 percent. Because very few children walk to school, it feeds on itself because you don't want to be the one child that's out there walking. You don't want your son or daughter walking by themselves.

We build these schools at some distance because the land is cheaper out there-big box stores are cheaper than smaller stores and we apply the same psychology to schools. But we're spending $1 billion a year just keeping the transportation system for California schools going.

In part we are beginning to pay high prices for the removal of exercise. There's no drug that works as well for depression as 1) social engagement, and 2), physical exercise. It works as well as Zoloft. So I wonder if part of the epidemic of depression in our children is related to removal of physical activity from their lives. Not only do we remove physical activity from their lives, but we also remove contact with nature. Los Angeles at the end of World War II was the leading agricultural county not just in California but in the United States. Think of the natural contact people had back then, then think of the change that has occurred in that much time.

I'll also argue that this change in the environment has something to do with the amount of Ritalin prescribed in the United States. What's striking to me is that as we look at studies in the use of Ritalin and how well that worked for hyperactivity versus exercise, and it turns out there were at least a 1,000 studies of drugs and the treatment of hyperactive kids, but we could find only four studies of exercise as a treatment for hyperactive kids. Yet every parent knows that a kid is a lot more manageable if they've had a chance to run around and get some exercise.

I would argue that thinking about the future demands, if we're paying 15 percent of GDP in heath care costs and are looking at an aging population that's going to be increasingly diabetic, we're going to have to change the environment to make people happier and healthier. What's the greatest environmental health threat in the 21st century? I actually think it's climate change.... You may think it's crazy, but it's real. The increases are phenomenal in the 50 years or so. Put the top five hottest years on record have occurred in the lifetime of your 8-year-old daughter.

I would argue that schools-the proximal environments we give our children-are important to this. Where we put them, how we design them, how we build them, light them, and how we teach children in them. Kids do better in smaller schools....

I would argue that we create bigger and bigger schools because they are economically efficient, but there are a lot of arguments for why kids actually do better in smaller schools. Bill Gates is running a campaign around the case for smaller schools and daylighting. It's fascinating reading the studies about daylighting: kids are more alert. Melatonin levels go down with more daylight, so there are things we can do just with more daylight in schools.

By bringing physical activity into our lives we get healthier. Studies show that walking 10,000 steps per day is a treatment for diabetes. Every doctor should be writing a prescription for exercise. They're too quick to write prescriptions for all kinds of drugs when the healthiest prescription is exercise.

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We ought to be designing communities that entice people to exercise. You don't need to go to the gym to exercise; you can have incidental exercise in your life if you walk to the store and buy a carton of milk or walk your dog. Even walking up one flight of stairs a day for a year is a pound of body weight.

I finished an Academy of Pediatrics policy statement on built environment, design, and health.... Maybe pediatricians ought to be saying to families, can your child walk to school? Is there green space accessible to that child? What's their environment like? Thinking about not just the home but the larger environment.

We need to tax high-fructose corn syrup, at a penny a teaspoon. We'd raise $2 billion a year, and I wouldn't use one nickel of that on stomach-stapling surgery. I'd use it on safe routes to schools, on nutrition education for teachers, for school gardens, for play areas and physical education programs. I'd use it for prevention of this disorder; it's a life or death issue.

Why talk about climate change? California is so far ahead of the rest of the United States you'd be shocked. Basically, we just signed on to the Kyoto Protocol and have really turned a corner. One thing we need to do is go back to walking to school. If you walk one mile, you put one gram of carbon into the atmosphere. If you drive the best possible Prius, you put 460 grams per mile into the atmosphere.

So let's say you get your 10-year-old nephew and he lives about a mile to school, and he decides he's going to walk to school every day for a year. If he does that, he burns 52 calories; over a year, he burns 18,000 calories, which is about five pounds of body weight-just by walking to school. If all 6 million kids in California walked one mile to school they would burn 32 million pounds of body fat. And suppose all those kids drive to school: they'd burn six ounces of gas per mile and it would be 96 million gallons of gas over the course of a year. That's 35,000 truckloads of gasoline to do what the legs that God gave them ought to be doing.

So what's good for our kids and their health and what's good for their neighborhood, school, and our city, state, nation, and planet are all the same thing.