NYC Green Carts SOMETHING!!! To Add to the Obesity Visit… Michael

NYC Green Carts SOMETHING!!! To Add to the Obesity Visit Michael P. Goldman, MD Lauren Sanlorenzo, MD

Rules PLEASE, if your ASCOM rings, just step out to answer it . Thank you!

Outline / Objectives Introduce the Concept of Green Carts Discuss Background Issue of Access to Produce and Define the Term “Food Deserts” Review Pattern of Adverse Health Outcomes Nationwide and Locally Revisit Green Cart’s Mission and Legislation Connect Green Cart’s Mission to Evidence Supported by the AAP Find Out What YOU Can Do About it!!!

The AMAZING CHONY RESIDENT’S Typical Obesity Visit Discuss patient’s BMI. 5 .2 .1 0 – Let’s go Campaign! Refer to nutritionist Hand out Green Bucks Tell families about local fitness center discounts Portion control through drawing the mock dinner plate Scare tactics – DM, MI, Stroke, Metabolic syndrome See you in 3 months for another uplifting discussion!!!!

The Newest Food Plate

3 Months Later Its only been 3 months and you have put on 7lbs Oh, you missed the nutrionist appointment? So now you’re drinking Iced Tea as opposed to coca-cola? WIC gave you WHAT coupon? You got another new video game!!!!!!! See you in 3 months try drinking water! WHAT IS GOING ON HERE AND WHAT ELSE CAN I DO HERE?

Why Green Carts Think for a second about grocery shopping options between 72nd St and 96th St. on the UWS and compare that to grocery shopping between 145th and 181st in Washington Heights. This unequal sharing of healthy food resources is not unique to NYC, but is seen across the country in both rural and urban low-income communities. The NYC Green Cart Initiative is an innovative approach to address the issue of access to fruits and vegetables in low-income neighborhoods in NYC

The Reasoning Behind the Cause Eating fruits and vegetables 3 or more times a day vs. less than 1 time a day is associated with: 27% lower risk of having a stroke 42% lower risk of dying from stroke 24% lower risk of dying from heart disease 15% lower risk of dying from all causes

The Reasoning Behind the Cause Eating 5 or more servings of fruits and vegetables per day significantly lowers the risk of developing type 2 diabetes.

Outline / Objectives Introduce the Concept of Green Carts Discuss Background Issue of Access to Produce and Define the Term “Food Deserts” Review Pattern of Adverse Health Outcomes Nationwide and Locally Revisit Green Cart’s Mission and Legislation Connect Green Cart’s Mission to Evidence Supported by the AAP Find Out What YOU Can Do About it!!!

How to define a food desert? According to the CDC: Food deserts are areas that lack access to affordable fruits, vegetables, whole grains, low-fat milk, and other foods that make up the full range of a healthy diet. The Department of Agriculture defines a food desert as: A Census tract where 33% or 500 people, whichever is less, live more than a mile from a grocery store in an urban area or more than 10 miles away in a rural area. AND At least 20% of the residents must live below the federal poverty line, currently 22,350 for a family of four. Although the term “food desert” can mean a literal absence of retail food in a defined area, studies of food deserts more commonly assess differential accessibility to healthy and affordable food between socioeconomically advantaged and disadvantaged areas.

Prevalence of food deserts Right now, 23.5 million Americans, including 3 million in New York City, and almost 4 million people across the state, live in areas known as “food deserts” .

Is CHONY in a food desert? The USDA created a website which mapped out food deserts , called Your Food Environment Atlas http://www.ers.usda.gov/Data/FoodDesert/ You can go to this website and search for your city to identify food deserts. Again on this atlas the government used the definition of an urban food desert as : “a census tract that is more than a mile from a grocery store”. This caused great controversy given that the USDA counted NYC bodegas, small corner stores that offer limited supplies, as grocery stores. With that consideration, the USDA finds there are no food deserts in the Bronx, Brooklyn or upper Manhattan, though local activists would beg to differ. Local officials estimate that if you excluded bodegas from the definition of “grocery stores” that approximately 3 million New Yorkers live in a food desert.

The Issue of Access In 2009, the Economic Research Service of the USDA reported: 7% of densely populated urban zip codes lack a grocery store or supermarket of any kind and 53% lack a chain supermarket. African-Americans are half as likely to have access to a chain supermarket than Caucasians, while Hispanic populations were one-third as likely. Independent, convenience type stores with higher prices were found to be far more common in minority communities. Small stores are also less likely to carry fresh fruits and vegetables.

Outline / Objectives Introduce the Concept of Green Carts Discuss Background Issue of Access to Produce and Define the Term “Food Deserts” Review Pattern of Adverse Health Outcomes Nationwide and Locally Revisit Green Cart’s Mission and Legislation Connect Green Cart’s Mission to Evidence Supported by the AAP Find Out What YOU Can Do About it!!!

Reviewing “The Scope of the Problem” Nationwide Obesity Trends – 2009 NYC DOH Community Health Survey by Neighborhood Obesity Rates Access to Medical Care Sugar Beverages Produce Consumption T2DM The theme, as you all well know, is that the neighborhoods that score badly in one category tend to score badly across the board!!!

Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2000 1990 2010 No Data 10% 10%–14% 15%–19% 20%–24% 25%–29% 30%

Obesity Trends by Neighborhood

Access to Medical Care

Physical Activity

Sugar Sweetened Beverage

Produce Consumption

Just one Consequence DM

Outline / Objectives Introduce the Concept of Green Carts Discuss Background Issue of Access to Produce and Define the Term “Food Deserts” Review Pattern of Adverse Health Outcomes Nationwide and Locally Revisit Green Cart’s Mission and Legislation Connect Green Cart’s Mission to Evidence Supported by the AAP Find Out What YOU Can Do About it!!!

The Food Cart Scene Prior to Green Carts 4,100 mobile food cart permits in NYC As many as 2,500 people are on waiting lists for permits Few carts sold fruits and vegetables - 10%

Green Cart Initiative In the Spring of 2008, the Laurie M. Tisch Illumination Fund seeded the NYC Green Cart Initiative with a leadership grant to increase the availability of fresh produce in low income neighborhoods throughout New York City. The Initiative addresses an urban issue with an innovative blend of public policy, private philanthropy and grassroots entrepreneurship. Designed to address issues of access and proximity (two factors strongly influencing consumption) by bringing fresh, affordable, high quality fruits and vegetables to high need communities. The goal of the initiative is to promote access to healthy food, by expanding the number of food carts that only sell fresh fruits and vegetables – ‘Green Carts’- in the New York City Neighborhoods that need them most.

Proposal The proposal was to create permits for 1,000 Green Carts in designated neighborhoods. The Green Carts would be able to sell unprocessed, unfrozen, raw fruits and vegetables . Green Cart areas were chosen to include only neighborhoods with more than 15% of residents surveyed consumed no servings or fruits and vegetables on the previous day, as reported in the 2004 Community Health Survey. In some neighborhoods with lowest fruit and vegetable consumption, that figure was nearly 26%. DOHMH identified and targeted five regions across New York City -- the majority of the Bronx, Northern Manhattan and East/Central Harlem, North/Central Brooklyn, Western Queens and Northern Staten Island -- based on their low household consumption rates of fruit and vegetables

Solving a Key Piece of the Problem

Permits A certain number of permits will be allocated for carts in the Green Cart areas in each borough, based on population in the designated areas: Bronx 350 permits Brooklyn 350 permits Manhattan 150 permits Queens 100 permits Staten Island 50 permits

Goals of program The City’s Department of Health and Mental Hygiene (DOHMH) estimated that Green Carts would: increase access to fresh produce in neighborhoods where produce consumption was low increase consumption of fresh produce by at least 75,000 New Yorkers save approximately 100 lives annually over the long term The positive health impacts of increasing fruit and vegetable consumption occur when consumption remains high for many years, so the positive health impacts of Green Carts will be seen over the long term.

Timeline of Green Cart Initiative On February 27, 2008, the City Council voted to approve the legislation. On March 13, 2008, Local Law 9 was signed by Mayor Bloomberg which established 1,000 permits for Green Carts.

Now Working on another Key Piece of the Problem Carts improved access, but affordability is another challenge Approximately ONLY 30 carts accept EBT!!! Wireless connection Battery Power Each EBT unit costs 900 – an upfront cost to the vendor!

Outline / Objectives Introduce the Concept of Green Carts Discuss Background Issue of Access to Produce and Define the Term “Food Deserts” Review Pattern of Adverse Health Outcomes Nationwide and Locally Revisit Green Cart’s Mission and Legislation Connect Green Cart’s Mission to Evidence Supported by the AAP Find Out What YOU Can Do About it!!!

Why this Matters To Pediatricians? We are a profession of prevention Early habits (like healthy eating) die hard, bad habits (like unhealthy eating) die harder! We have few tangible resources to help our obese patients combat obesity

We Like Evidence Based! But there isn’t evidence to say any one of the above strategies will solve the obesity epidemic. And the TRUTH IS that this problem is way beyond a purely medical issue! But allow us to share what the experts recommend we do with respect to produce’s role in preventing, assessing and treating obesity.

AHA’s Pediatric Dietary Strategies for Individuals Aged 2 Years: Recommendations to All Patients and Families - Balance dietary calories with physical activity to maintain normal growth - 60 min of moderate to vigorous play or physical activity daily - Eat vegetables and fruits daily, limit juice intake - Use vegetable oils and soft margarines low in saturated fat and trans fatty acids instead of butter or most other animal fats in the diet - Eat whole-grain breads and cereals rather than refinedgrain products - Reduce the intake of sugar-sweetened beverages and foods - Use nonfat (skim) or low-fat milk and dairy products daily - Eat more fish, especially oily fish, broiled or baked - Reduce salt intake, including salt from processed foods

AAP Dietary Recs Good nutrition, a physically active lifestyle, and absence of tobacco use contribute to lower risk prevalence and either delay or prevent the onset of cardiovascular disease. These observations have established the concept of prevention of the development of cardiovascular risk factors in the first place, now called primordial prevention.

Primordial Prevention Is Essentially 5 2 1 0

Primordial Prevention 5 2 1 0 AND No skipping meals Appreciate/work within cultural differences, Address eating behaviors minimize food intake outside of the home, Involve the whole family in this lifestyle changes.

AAP Dietary Rec’s Around 9 months – During the transition from a milk-based diet to adult foods, the types of vegetables consumed change adversely. E.g. Deep-yellow vegetables are consumed by 39% of children at 7 to 8 months and by 13% at 19 to 24 months, French fries become the most commonly consumed vegetable by this age. ***Parents can make age appropriate baby / table foods if they had access to Produce! – Green Carts!!!

AAP Dietary Recs 2-6 Years Provide a wide variety of nutrient-dense foods such as fruits and vegetables instead of high-energydensity/nutrient-poor foods such as salty snacks, ice cream, fried foods, cookies, and sweetened beverages Key issue identified Parents are the role models and should model healthy eating and healthy FOOD SHOPPING ***Green Carts Attempt to intervene on this level.

AAP Dietary Recs 6y – adolescents – Parallel to the psychosocial transition from dependence on parental authority to independent thought processes, food choices and purchases are increasingly made by the adolescent. – Peer pressure for conformity, in part driven by media promotion of fast food directly to teens, makes overeating natural. – Currently, adolescents have an increased intake of sweetened beverages, French fries, pizza, and fast food entrées, including hamburgers, and a consequent lack of recommended fruits, vegetables, dairy foods, whole grains, lean meats, and fish. – ***Green Carts In front of Hospitals, Schools, CBOs can intervene here.

AAP on Produce Preventing Obesity An ADA evidence analysis concluded that the evidence supports a modest effect of fruit and vegetable intake in protecting against increased adiposity in children. Fruits and vegetables have been promoted for the prevention of childhood obesity because of their low energy density, high fiber content, and satiety value. Fruits and vegetables are most likely, compared with other food groups, to be consumed in inadequate amounts by children 34 Several studies found no association between fruit and vegetable intake and childhood adiposity; nevertheless, in none of the 17 studies reviewed in the ADA evidence analysis was increased fruit and vegetable in- take related to increased adiposity.

Outline / Objectives Introduce the Concept of Green Carts Discuss Background Issue of Access to Produce and Define the Term “Food Deserts” Review Pattern of Adverse Health Outcomes Nationwide and Locally Revisit Green Cart’s Mission and Legislation Connect Green Cart’s Mission to Evidence Supported by the AAP Find Out What YOU Can Do About it!!!

School Lunches an Ex. of the Peds’ Role in Advocacy Great Bills won’t pass without you! Healthy Hunger-Free Act of 2010 Look who you are up against! 2010 - Congress blocked Dept of Agriculture from limiting servings of potato (French Fries) to 2 servings a week Potato Growers and frozen food companies (pizzas) lobbied against this bill and were able to make the Bill less restrictive than the Obama Admin had hoped for. Conservatives said “the Gov’t should not tell children what to eat.” But with support from the AAP and others, A Law was passed 1/27/12 changing school lunches!!!!!!!!!

What CAN we do for Green Carts / Markets? Conclusion: Existing research provides clear evidence that food deserts exist in numerous low-income communities and communities of color across the country, and that they have significant negative impacts on health, social equity, and local economic development. Further, there is a legitimate, though not fully evidenced based data to support the role of fresh produce in the prevention, assessment and treatment of obesity. Action: 1. Federal Government 2. Local Government 3. Continue to increase your own knowledge of community resources

Federal Level Advocacy In December 2009, 39 members of Congress both political parties issued a resolution in the House of Representatives recognizing the need for national policy to address limited access to healthy food in underserved communities. In February 2010, the federal government under the Obama Administration announced the details of an over 400 million Healthy Food Financing Initiative (HFFI), which will bring grocery stores and other healthy food retailers to underserved urban and rural communities across America. The HFFI is a partnership between the Departments of Treasury, Agriculture, and Health and Human Services. The HFFI is a key component of the First Lady’s Let’s Move campaign to reduce childhood obesity.

Current Legislation: H.R. 3525: Healthy Food Financing Initiative Sponsor: Rep. Allyson Schwartz, D-PA Co-Sponsors: Eleanor Norton [D-DC], Earl Blumenauer [D-OR], Robert Brady [D-PA], Michael Burgess [R-TX], Marcia Fudge [D-OH], Jesse Jackson [D-IL]. Status: This bill is in the first step in the legislative process. Explanation: Introduced bills first go to committees that deliberate, investigate, and revise them before they go to general debate. The majority of bills and resolutions never make it out of committee. Introduced on November 30, 2011. Referred to Committee- Referred to House of Agriculture Reported by committee - TBD House Vote - TBD Senate Vote - TBD Signed by President- TBD

Letter Writing To show our support of H.R. 3525 we could: Write Charles Rangel, the representative for New York’s 15th congressional district (this is the district where CHONY is located) stating our support for this bill. Write to our state senators: Kristen Gillibrand or Charles Schummer to state our support of H.R. 3525. Of note, Kristen Gillibrand is New York’s first member of the Senate Agriculture Committee in nearly 40 years! She is already a supporter of the Green Carts Program!

Local Advocacy Specific to the Green Cart Initiative An organization called Citizens’ Committee for Children of New York Inc. (CCC) collected data during the first year of Green Cart implementation to determine if the presence of Green Carts had a positive impact on the consumption of fruits and vegetables in targeted communities. Summary of key findings, which lead to key advocacy issues Finding #1: Knowing about Green Carts increased the likelihood of usage. Constituents who saw or heard advertising were more likely to purchase from a Green Cart than those who had not seen or heard such an advertisement. ADVOCACY: Expand public marketing of Green Carts

Local Cont Finding #2: For those who used Green Carts, the location played a critical role in consumer usage. Among Green Cart users: 67% of constituents responded that the primary reason for shopping at a Green Cart was the convenient location of the cart. ADVOCACY: Encourage the targeted placement of Green Carts on public property, such as NYCHA facilities, Public Hospitals, Child Health Centers. **THINK CHONY** Finding #3: Green Carts were reaching targeted populations. When vendors were asked on the street, “Who purchases from you the most?” nearly 60% of those who responded said “children and families.” ADVOCACY: Ask the city to facilitate the placement of Green Carts in close proximity to CBO’s and allow for CBO cart adoption or sponsorship. **THINK Aliancia Dominicana**

Continued. Finding #4: Vendors were interested in efforts to increase usage of Green Carts by poor and working poor consumers. Vendors who participated in focus groups indicated that they need the ability to accept Electronic Benefit Transfer cards (EBT) if they are to be profitable in high poverty districts. ADVOCACY: Ensure that all Green Carts have access to EBT terminals so they can accept food stamp (SNAP) benefits as well as WIC allotments. ***A Work In Progress***

What You Can do in Clinic Talk to your patients about Green Carts. Print out a few recipes from NYC Green Cart Cookbook to have for your patients! http://www.lmtilluminationfund.org/pdf/ GreenCartCookbook FINAL 2.28.pdf

Increase your own knowledge on Green Carts Attend local screening of The Apple Pushers. The Apple Pushers, written and directed by Mary Mazzio, narrated by Edward Norton, and underwritten by the Laurie M. Tisch Illumination Fund, follows immigrant street vendors who are rolling fresh fruits and vegetables into the inner cities of New York (where finding a fresh red ripe apple can be a serious challenge). http://www.applepushers.com/ Next Screening: NEW YORK February 6, 2012 Hosted by Citizens Committee for Children

QUESTIONS?