The global campaign Healthy Cities report

In our first Healthy Cities report, Diabetes Voice edgement and support from a distinguished list highlights municipal and national governing poli- of international leaders and influential scholars. cies that are trailblazing new directions for hu- We briefly review his extraordinary final term man health. and present supporting words from another New York City resident, Marion Nestle, Professor of Mayor Michael Bloomberg has dominated his , Food Studies, and at New mayoral terms with strong government leader- York University. Winds of change and fresh air ship providing unconventional initiatives for New are also moving across other regions in North York City’s public health problem. His controver- America. In an interview with members of Mexi- sial policies have gained worldwide acknowl- co’s Health Secretariat, we learn about the city’s

The new health revolution: New York City

Elizabeth Snouffer

A healthy city is one that WHO, Health Promotion Glossary first ‘healthy cities’ instalment, we praise is continually creating and (1998): the efforts of Mayor Michael Bloomberg of improving those physical WHOs Healthy Cities programme is a New York City, who has forced change on and social environments and long-term international development issues related to public health, including expanding those community initiative that places public health ‘high tobacco cessation, and campaigned in resources which enable people on the agendas of decision makers in support of healthy nutrition. The world is order to promote comprehensive local watching Mayor Bloomberg’s new health to mutually support each strategies for health protection and sus- revolution. Will his initiatives control the other in performing all the tainable development’. Focussing on cit- obesity and diabetes epidemic in New functions of life and developing ies that represent the best of community York? Only time will tell. to their maximum potential. participation and empowerment, and intersectoral partnerships creating a Mayor Michael Bloomberg, Chief health-supportive environment, in our Executive of New York City since 2002,

22 DiabetesVoice June 2013 • Volume 58 • Issue 2 the global campaign Healthy Cities report

anti-smoking policies, and new educational cam- diet also require government interventions tar- paigns for the prevention of obesity and diabetes. geting nutrition, physical activity and obesity. Once the world’s most polluted urban centre, Mexico City now seems intent on transforming These thought leaders, health ministries and its public health environment to the highest pos- governments have all prioritised the escalating sible standard. In our final segment, Pilar Garcia public health burden related to Non-communi- Crespo sheds some light on why Spain has been cable Diseases (NCDs). Although unique, all of ranked as one of the healthiest countries in the these individual or regional voices believe in the world. Surprisingly or not, people residing in the power of policy to encourage and provide greater birthplace of the heart-healthy Mediterranean opportunities for the future of human health.

has taken on the forces of Big Tobacco the privatized health care system. New The researchers also concluded that and the food and beverage industry, and York State has the fourth largest number the over-consumption of sugary drinks succeeded in making change and reform of people living with diabetes, behind was to blame. Sadly 45% of all newly in ways no one could have imagined. California, Florida and Texas respec- diagnosed cases of type 2 diabetes for In his quest to reclaim the vibrancy of tively, and in a city where 800 languages New York State occur in children.3 Age, the Big Apple and wipe out poverty, are spoken, more than 22% of adult New black race, Hispanic ethnicity, elevated unproductivity, and disease, what has York City residents are obese. Health body mass index, and low educational been most visible in his relentless cam- disparities are traceable in part to fun- attainment have all been cited as the most paign for public reform are enforceable damental social and environmental predominant features for diabetes risk in restrictions of sugar, saturated fats and problems. According to Scott Stringer, New York City.4 The economic burden smoking all in the name of health. Manhattan Borough President, ‘the scar- is hard to ignore. According to the New city of fresh foods and produce preva- York City Department of Health, obesity In a city where 800 lent in low-income neighbourhoods related healthcare problems, including languages are spoken, and communities of colour, contribute diabetes, account for USD 4 billion a year. to the disproportionate disease burden For every person diagnosed with type 2 more than 22% of carried by the city's minority popula- diabetes, the estimated cost to the New adult New York City tions’. In one study conducted from 2002 York Health and Hospitals Corporation residents are obese. to 2004, New York City’s rates of obesity is USD 400,000. and diagnosed diabetes both increased Across the United States, obesity and by 17% and researchers concluded that New Health Revolution diabetes exist as two of the most seri- during that time the adult population had In an effort to transform the impaired ous threats to the total population and gained ten million pounds in weight.1,2 public health status of his city, Mayor

June 2013 • Volume 58 • Issue 2 DiabetesVoice 23 The global campaign

Liberty from Big Soda

Marion Nestle

While some people believe that Mayor Bloomberg’s soda regulations go too far, Marion Nestle, a professor of nutri- tion at , believes that they may not go Bloomberg decided to take charge; de- which was set to take effect on 12 far enough. termining average New York citizens March 2013. Most of all stakeholders don’t know what’s best for them. He involved in helping New York’s obe- has likened his municipal restrictions to sity problem, including public health Mayor Bloomberg’s 16 ounce cap outlawing drunk driving or protecting officials, scientists, nutritionists and on sugary sodas that should have citizens from potential terrorists. The medical professionals, believe curtail- gone in effect on 12 March 2013, Mayor’s most controversial initiatives ing the consumption of sugar-sweetened would have prohibited restaurants, include: the ban of trans fat in cooking beverages is a significant step in the ef- movie theatres, sports venues and oils for the city's 24,000 food establish- fort to reduce obesity food carts from selling extra-large ments; an ordinance requiring chain res- and to promote citi- portions of sugar-packed drinks. taurants in the city to display calorie in- zens’ general health formation on menus and menu boards; and wellness. (Please Stay calm. This does not signal and illegalizing smoking in the city’s see Marion Nestle’s article, the end of democracy in America. parks, beaches, marinas, boardwalks Liberty from Big Soda.) The Mayor’s and pedestrian plazas. According to Dr. third and final term in office ends If we want Americans to be Susan Kansagra, an assistant commis- this year, and while his healthy, we are go- sioner at the New York City Department Soda Ban was invali- ing to have to of Health and Mental Hygiene, since dated the day it was take actions like Bloomberg took office, New York City’s to take effect, one this – and many smoking rate has dropped from 22% to thing is clear: in the more – and do just above 14%. effort to minimize so soon. It’s long the risks associated past time to tax Since Bloomberg with the exposed and sugar soda, crack took office, New York unstable health status of down further on City’s smoking rate New York, the Mayor has what gets sold in our provided unprecedented schools, tackle abusive has dropped from 22% awareness to the 21st marketing practices, to just above 14%. century health epidemic demand a redesign of for Non-communicable labels – and extend the To date, the most provoking initiative Diseases — chiefly obesity soda cap, no matter how has been the Bloomberg ‘Soda Ban’, and type 2 diabetes. controversial it may seem.

24 DiabetesVoice June 2013 • Volume 58 • Issue 2 the global campaign

This must be the beginning, not the end, health-speak – and are content with that only puts ‘better-for-you’ drinks in of efforts toward a healthier America. amount. So a reasonable goal of pub- school vending machines, but sugar- lic health intervention is to change the filled sports drinks are still liquid In short, we need a series of serious default drink to a smaller size. Hence: candy. And kids should not have to changes to make the healthy choice the Bloomberg’s 16 ounce size cap. pay for water in schools. easy choice. The soda size cap is a nudge in that direction. You will still be able From my nutritionist’s perspective, a ■ Restrict marketing of sodas to children. to drink all the soda, and down all the 16 ounce soda is still generous. Just one Soda companies market extensively to sugar, that you want. The cap on soda contains the equivalent of 12 packets children and adolescents, especially size makes it just a tiny bit harder for of sugar. Just one provides 10% of the those in low-income neighborhoods. you to do so. daily calorie needs of someone who typi- We already have restrictions on ciga- cally eats 2,000 calories a day. Just one rette and alcohol marketing to kids. That ‘tiny bit harder’ is its point. If you contains the upper limit of sugar intake It breaks no new ground to add sodas have to order two sodas instead of one, that health officials recommend for an to the list. maybe you won’t. If you have to add sug- entire day. Once you down a 16 ounce ar to your coffee drink yourself, maybe soda, it’s best to stop right there. ■ Show full calories on the front of con- you will only add one or two teaspoons tainers. The current way calories are instead of the ten or more someone else City officials concerned about the health tallied, in a measure called ‘calories- put in there for you. of their citizens, as those in New York per-serving,’ is confusing because the most definitely are, want to do every- servings are unrealistically small and For a public health nutritionist like me, thing they can to prevent obesity and the people don’t do the math. the soda size cap is a terrific idea. Unlike illnesses that go with it. Their rationale other foods, sodas are a unique target for is humanitarian, but also fiscal. Poor Actions like these will evoke ferocious intervention. They contain sugars – and health is expensive for both individuals opposition from the soda industry, and sugar calories – but nothing else of nu- and society. it will spare no expense to make sure tritional value. They are candy in liquid such things never happen. Polls say that form. Candy has a place in healthy diets, We can thank Big Soda – Coca-Cola, many New Yorkers oppose the 16 ounce but a small one. So it should be for sodas. Pepsi and their trade association, the cap and would oppose measures like American Beverage Association – for this, too. It’s no surprise that people who drink the contribution of big sodas to weight large amounts of liquid candy have gain. The soda industry may profess But I can’t tell whether the opposition worse diets, are heavier, and have more to care more about your well-being comes from genuine concern about health problems than those who do not. these days, but it ultimately will not do limits on personal choice or because And it looks like the body doesn’t com- anything to promote health if doing so soda companies have spent millions of pute the calories from liquid sugars as harms sales. dollars to protect their interests and gin accurately as it does for sugars in foods. up histrionic, misinformed opposition. On top of that, big sizes make the prob- Here are some additional actions New lems worse. To state the obvious, larger York City should take, if only it were The 16 ounce soda is the new default portions have more calories. allowed to: size in New York City. While waiting for the court decision and for politics But big sizes also have other effects. They ■ Tax sodas. Raising the price of sodas to play out, why not give it a chance? induce people to eat and drink more than would discourage sales, especially Maybe it will help you live a healthier they would if given smaller portions. Big among young people most suscep- and longer life. sizes confuse people into underestimat- tible to marketing efforts and most ing the number of calories consumed. vulnerable to weight gain.

Most people eat whatever size is in ■ Remove vending machines from Excerpt from the NEW YORK DAILY front of them – the ‘default,’ in public schools. Yes, the Beverage Association NEWS, 8 March 2013

June 2013 • Volume 58 • Issue 2 DiabetesVoice 25 The global campaign

Health snapshot: Spanish steps to a healthy city Mexico City Pilar García Crespo Interview with Armando Ahued Ortega, Rafael Alvarez Cordero and Mónica Hurtado Gonzalez

Do you believe Mayor Bloomberg’s result in improved collaboration with In 2011, according to the National initiatives would work in Mexico City? the Health Secretariat at the Legislative Statistics Institute, in Spain the Mexico Federal District in 2004 adopted Assembly responsible for formulating life expectancy at birth was 82.1 a policy for Health Protection of Non policies and reforms. years for both sexes (84.9 years Smokers which prohibits smoking in for women and 79.1 for men). In public indoor spaces. Policies have also Name a few activities that promote Madrid it is 83.6 years for both been put in place requiring producers to healthier lifestyles. sexes (86.1 for women and 80.7 include information of food products. In 2008 the Health Secretariat of Mexico for men). However, we need to educate people on implemented the on-going campaign how to read labels and how to use this ‘Muévete y Métete en Cintura’ (Move and information. At the Health Secretariat change your habits) which promotes the we have worked towards empowering concept that a combination of a healthy people through training and lectures diet, physical activity and healthy choices to provide tools that will allow them to creates a healthier society. We are also choose healthier options and combina- promoting a culture of self-management, tions. The Health Secretariat’s efforts wherein the individual is educated to have been acknowledged through the make healthy choices. Bloomberg Award*. How many people are diagnosed with What public health policies has Mexico diabetes? City established? In 2012, 582 new cases of type 1 diabe- Since 2009 Mexico City has opened tes were diagnosed and 28,297 cases of centres for the management of obe- type 2 diabetes. In a screening pro- sity. We recently opened a Specialized gramme, 290,754 people were tested and Centre on Diabetes Management, which just under 20% were found to be positive provides diabetes education and treat- and required further investigation. ment of complications, including sec- tions focused on nutrition and sports. With the creation of the Council for the Prevention and Comprehensive Care for Obesity and Eating Disorders we intend to improve the relation between the pub- lic and private sectors. This action will

*In 2009, The Union Mexico Office developed the first case study for smoke-free environments, focusing on Mexico City. The successful implementation of the 100% smoke-free city law led Michael Bloomberg to award a 2009 Bloomberg Award for Global Tobacco Control to the Mexico City Secretary of Health.

26 DiabetesVoice June 2013 • Volume 58 • Issue 2 the global campaign

Elizabeth Snouffer, Marion Nestle, Armando Ahued Ortega, Rafael Spanish steps to a healthy city Alvarez Cordero, Mónica Hurtado Gonzalez and Pilar García Crespo Elizabeth Snouffer is Editor of Diabetes Voice. Marion Nestle is Professor in the Department of Nutrition, Food Studies, and Public Health at New York University. She is author of three prize-winning books including her most recent: Why Calories Count: From Science to Politics (2012). (www. foodpolitics.com, twitter @marionnestle) The significant development in the Activity and Obesity Prevention) with Armando Ahued Ortega is Health Secretary and Council Vice-president, Council for the last decades of the general socioeco- the aim of raising awareness among Prevention and Comprehensive Care for nomic status, the development of the the population on the problem obe- Obesity and Eating Disorders in Mexico FD, Health Secretariat Mexico Federal District. health and education systems - both sity poses to health. This programme Rafael Alvarez Cordero is Obesity free and universal - and the pension promoted initiatives that enabled the Programme Responsible of Council for the and retirement programmes have public, especially children and ado- Prevention and Comprehensive Care for Obesity and Eating Disorders in Mexico FD, contributed to a healthier Spain. The lescents to adopt healthy lifestyles Health Secretariat Mexico Federal District. main success factors of the Spanish through a healthy diet and regular Mónica Hurtado Gonzalez, is the Technical healthcare system can be attributed to physical activity. NAOS aims to con- Secretary for the Council for the Prevention and Comprehensive Care for Obesity and the development of the 1986 Health tinue to provide a platform for any Eating Disorders in Mexico FD, Health Act: universal healthcare, the new action that will help meet this goal. Secretariat Mexico Federal District. model of primary care, the develop- It integrates the efforts of all stake- Pilar García Crespo is responsible for the ALAS Programme, Madrid, Spain. ment of public health policies, the im- holders: public, government, experts, plementation of a single system with private sector. This way, the sectors of a national test for accessing training action influenced by the NAOS strate- for intern and residents doctors, the gy are multiple: family, school environ- implementation of administrative ment, businesses and health systems. systems for the provision of technol- The Strategy received an award from ogy to health centres and the salary WHO European Regional Office at the system was not very high for all public Ministerial Conference in Istanbul in health professionals. November 2006.

In 2005, the Ministry of Health, Madrid has adapted the NAOS strategy through the Spanish Agency for into their ‘Gente Saludable’ (Healthy References Food Safety and Nutrition, launched people) programme ALAS (diet, physical 1. Obesity and Diabetes in New York City, 2002 NAOS (Strategy for Nutrition Physical activity and health). and 2004: http://www.cdc.gov/pcd/issues/2008/ apr/07_0053.htm?s_cid=pcd52a48_e

2. Rehm CD, Matte TD, Van Wye G, et al. Demographic and behavioral factors associated with daily sugar-sweetened soda consumption in New York City adults. Journal of Urban Health 2008; 85(3): 375-85.

3. New York Diabetes Coalition. New York Focus on Diabetes: New York State Facts and Figures. www.nydc.or/ny_focus.php

4. Tabaei BP, Chamany S, Driver et al. Incidence of self-reported diabetes in new york city, 2002, 2004, and 2008. Prev Chronic Dis 2012: 110320.

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