Introduction and Session 1

Ornamental Horticulture Roundtable

A health creating society

• Modern societies actively market unhealthy lifestyles

WHO European Region

Building a health creating society

Nigel Crisp

Health and Horticulture:

building a health creating society

4th July 2016Nigel Crisp



WHO European Region


Nigel Crisp



WHO European Region

• Health is made at home, hospitals are for repairs

Traditional African saying


Nigel Crisp

The UK and Europe

• Children• Older people • Mental illness• Inequalities


Nigel Crisp

Everyone has a role to play…

A health creating society where everyone – gardeners, architects, teachers, employers, citizens, business - has a role to play in creating healthy robust citizens and communities


Nigel Crisp


In 1948 all the people and organisations involved in health care came together around the common goal of health care for allNow we need everyone and everybody that affects health to come together in a common goal to build a health creating society


Nigel Crisp



WHO European Region


Nigel Crisp

Session 1: Strategic & academic evidence: health, wellbeing & horticulture

1000 Dr William Bird (GP & Intelligent Health)Horticulture, Health & Wellbeing: a GP’s perspective

1010 Dr Justin Varney (Public Health England)How Horticulture & PHE can work together

1020 Dr Agnes van den Berg (Environmental Psychologist)An International Perspective: Greenspace & Health

1035 Dr Ross Cameron (Sheffield University)Gardening: Value in terms of Human Health & Wellbeing

1045 Questions on Session 1

Dr William Bird MRCGP MBE4th July 2016

Health and Horticulture ConferenceA GP’s Perspective

© 2015 Intelligent Health

We were designed

to be connected to nature

The StoryYet 54% of the world’s population live in cities

Is this disconnection the underlying cause of the epidemics of obesity and other chronic diseases?Do we need healthy landscapes?


If we take an hour to equal 1,000 years,then four days is 100,000 years – the timefrom the origin of mankind to today

4 daysago

100,000years ago

hunter gatherers

10 hoursago

10,000years ago agriculture

4 hoursago

4,000years ago civilisation

10 hoursago

10,000years ago agriculture

4 hoursago

4,000years ago civilisation

technologyindustrialisatio

nindustrialisation

9 minutesago

9 minutesago

80 secondsago


Sociable Green Valued

Our factory setting is to be in a sociable group, supportive environment

and have a purposePeople Place Purpose


Loneliness Hostile Rejection

People Place Purpose

Fear and Chronic Stress


How does nature benefit health?(a) Less stressed,

(b) More exercise,

(c) More positive social interactions and (d) Better quality environment for health promotion (i.e. has lower levels of air pollution)

Hartig T., Mitchell R., De Vries S. and Frumkin H. (2014) Nature and health. Annual Review of Public Health 35, 207–228.




The Effect of Trees on Cognitive Performance

–3–2–101234567

No Tree Min Awareness Mod Awareness Heightened Awareness

Lin, Ying-Hsuan, et al. "Does awareness effect the restorative function and perception of street trees?“ Cognitive Science 5 (2014): 906.

Digit Span Backward Test


Exposure to Neighbourhood Green Spaceand Mental Health

Beyer, Kirsten MM, et al. Int.J of environmental research and public health 11.3 (2014): 3453-3472


Association Between Trees, Vegetation, Depression and Stress

25% more Tree Cover 25% Higher NDVI 25% more Greenspace

–1.6

–1.4

–1.2

–1.0

–0.8

–0.6

–0.4

–0.2

0.0

Depression Stress

Normalized Difference Vegetation Index (NDVI)

Beyer, Kirsten MM, et al. Int.J of environmental research and public health 11.3 (2014): 3453-3472


Green Space reduces Health Inequalities

No green Little green Some green More green Very green1.0

1.2

1.4

1.6

1.8

2.0

2.2

Highest Income

Linear (Highest Income)

Middle Income

Linear (Middle Income)

Lowest Income

Linear (Lowest Income)

Exposure to green

Mitchell, R. and Popham, F. (2008) Effect of exposure to natural environment on health inequalities:an observational population study. The Lancet 372(9650):pp. 1655-1660.

Incidence Rate Ration


Nature and the Unborn Child

HighBlood Pressure

in pregnantwomen increasedby 14% for every300 meters away

from greenspace

Birthweight andbaby’s head

size were largerwithin the 500

metres ofgreen space

1. Grazuleviciene R et al Int J Environ Res Public Health 2014 11 2958-29722. Dadvand P Env Health Perspectives 120 10


ChronicStress

Anxiety anddepression

PhysicalInactivit

yPoor diet


Chronic Stress

StressHormones

PhysicalInactivity

And otherpoor healthbehaviours

Chronic Inflammation

Mitochondria as a key component of the stress response. Manoli et al. Trends in Endocrinology and Metabolism Vol 18 No 5 2007


ChronicInflammation

Immune systemis constantlyswitched on


Inflammation: ‘the cause of causes’

ChronicInflammation

Starts in childrenas young as6 years old

ArthritisArthritis

CancersCancers

DiabetesDiabetes

ObesityObesity

Dementia

Dementia

Cardiovasculardisease

Anxiety andDepression


Loneliness Hostile Rejection

People Place Purpose

Fear and Chronic Stress


Chronic Stress

StressHormones

PhysicalInactivity

And otherpoor healthbehaviours

leads to inflammationMitochondrial damage and telomere shortening

Depression

Mitochondria as a key component of the stress response. Manoli et al. Trends in Endocrinology and Metabolism Vol 18 No 5 2007

Cancers Diabetes DementiaCardiovascular


Adding Quality of Green SpaceMeasures of Quality: ● Accessibility, ● maintenance, ● variation, ● naturalness, ● colourfulness, ● clear arrangement, ● shelter, ● absence of litter, ● general impression.

Dillen, S.M.E. van, Vries, S. de, Groenewegen, P.P., Spreeuwenberg, P. Greenspace in urban neighbourhoods and residents’ health: adding quality to quantity. Journal of Epidemiology & Community Health: 2012, 66(6)

Green or BlueWillingness to visit 0-10

0

10

9

8

7

6

5

4

3

2

1

0

5.96 Urban Blue Space p= <0.01

4.89 Urban Green Space P= <0.01

3.66 Urban No Nature

5.83 Woodland open countryside

7.68 coast

7.40 open water

White M.P., Smith A., Humphryes K., Pahl S., Snelling D. and Depledge M. (2010) Blue space: the importance of water for preference, affect and restorativeness ratings of natural and built scenes. Journal of Environmental Psychology 30, 482–493.

http://www.intelligenthealth.co.uk/



Green Gym Vs Aerobics

Comparison of heart-rate response during two sessions of activity

0

50

100

150

200

Time Minutes

Heart Rate

Green GymStep aerobics V Reynolds 1999

OCHRAD


To make a step change inactivity levels we need to be bold

Let’sremove

boundariesand turn a whole

town into aplayground!


Step change across a community


Beat the Street East London

Exploring the local area (66%)Getting fit (54%) Having fun (54%) Spending time with friends or family (53%) and feeling more healthy (52%)Winning Prizes (13%)


Beat the Street Reading

2014 registration 2014 registration3 months after

2015 registration 2015 registration3 months after

0%

10%

20%

30%

40%

50%

60%

35%

45%36%

45% 46%

56%

40%

47%

Took part in 2014 only Took part both years Took part 2015 only

Over two years in Reading there has been a 20% increase in the number of peoplereaching the Government recommended activity levels of 150 minutes a week


• Disconnection from nature causes chronic stress

• We eat badly and exercise less• More visceral fat, inflammation • Result: an epidemic of chronic

disease e.g. diabetes , heart disease

• Being healthy is about friends, family, nature and feeling good about ourselves.

• Nature reduces stress connects people, increases activity and is generally more healthy

We are designed

to be Hunter

Gatherers

The Story


Building Active Communities

[email protected].

uk

Dr Justin Varney National Lead for Adult Health and [email protected]

How Horticulture and Public Health can work together to improve the health of the nation

About Public Health England

• We protect and improve the nation's health and wellbeing, and reduce health inequalities.

• Locally focussedo 4 regions, 9 centreso 8 Knowledge & Intelligence hubso Other local presence

• Key roles:1. System leadership2. Health protection3. Local support

41 How Horticulture and PH can work together

42

Overview

• The common challenge on Non-communicable disease

• Responding to the challenge• The evidence: Horticulture and health • Looking ahead

How Horticulture and PH can work together

The current and future challenges for health and social care in the UK

•Addressing the health and wellbeing gap •Healthy life expectancies gap•Increasing burden of preventable disease•Persistent health inequalities

•Addressing the care and quality gap•Persistent variations in healthcare

•Addressing the financial gap•Opportunity costs of not having a prevention focus

The need for a system wide approach of communities supported by their NHS, local authorities and voluntary sectors. 43 How Horticulture and PH can work together

44 PHE Conference 16 September 2015

Changes in causes of Disability Adjusted Life Years 1990-2013

Source: Newton et al. (2015) Changes in health in England, with analysis by English regions and areas of deprivation, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet

www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00195-6.pdf

http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00195-6.pdf


Why prevention matters

46

Disease risk factors in England

Newton et al. (2015) Changes in health in England, with analysis by English regions and areas of deprivation, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet

47

To improve & protect the nation’s health & wellbeing and improve the health of the poorest, fastestOutcome 1) Increased healthy life expectancy – taking into account health quality as well as length of lifeOutcome 2) Reduced differences in life expectancy between communities (through greater improvements in more disadvantaged communities)

Improving the wider determinants of health

1

19 indicators, including:• People with mental

illness or disability in settled accommodation

• Sickness absence rate• Statutory

homelessness• % of population

affected by noise• Use of green space• Social connectedness• Fuel poverty

Health improvement2

24 indicators, including:• Excess weight• Alcohol-related

admissions to hospital• Proportion of physically

active and inactive adults

• Self-reported wellbeing• Falls and falls injuries

in the over 65s

Health protection3

7 indicators, including:• Air pollution

• Public sector organisations with Board approved sustainable development management plans

Healthcare & public health preventingpremature mortality

4

16 indicators, including:• Infant mortality• Mortality from causes

considered preventable• Mortality from

cardiovascular disease• Mortality from

respiratory diseases• Excess winter deaths


How PHE is addressing these challenges


Horticulture & Health

Spectrum of intervention types, methodologies and strength of evidence

• Therapeutic garden schemes• Green Gyms• Health walks• Therapeutic landscapes• Garden schemes• Workplace Wellbeing Charter

How the money flows

49 http://www.kingsfund.org.uk/sites/files/kf/media/nhs-structure-2015.pdf

An alternative guide to the NHS

50 http://www.kingsfund.org.uk/projects/nhs-65/alternative-guide-new-nhs-england

The alternative guide to the NHS in England

Key Commissioning Priorities


• Health • Acute pressures (A&E, GP apt)• Recurrent or prolonged treatment costs

• Public Health• Preventable mortality & morbidity• Obesity – predominantly childhood• Life course issues – childhood, old age

• Social Care• Adult social care costs for residential/domiciliary care

• Employers• Productivity & sickness absence

TIMESCALE OF RETURN ON INVESTMENT

52

Evidence

Growing and strengthening evidence base for cost-effective interventions delivered by horticulture

Particularly strong for:• Mental health / Dementia• Physical activity • Wellbeing• Air quality

Growing evidence base in relation to physical health, with some good evidence around initiatives such as green gyms


Cultural commissioning: a public health perspective

Working together


Historically commissioning of horticulture schemes for health has been very small scale primarily non-recurrent pilots & grants.

Moving to sustainable provision requires cultural shifts for both commissioners and providers.

Recognition that horticulture is a wide spectrum encompassing big business and a large industrial workforce

Recognition that providers need to deliver the outcomes commissioners are commissioning for and in a measurable way.

Lots of learning from cultural and physical activity sectors who are on the same journey.

Looking ahead• Ageing population with growing

burdens of multiple health challenges

• Working age is increasing and millennials will often have portfolio careers

• Public sector is refocusing and prioritising on outcome based commissioning

• Inclusive universalism vs targeted minority approaches


Prof. Dr. Agnes van den Berg

An international perspective: Greenspace and health

56

Accumulating evidence

19901992

19941996

19982000

20022004

20062008

20102012

20140

100020003000400050006000

# hits google scholar “greenspace health"

Epidemiological research

32

24 2620

108

05

101520253035

Num

ber p

er 1

000

depression asthma diabetes

10% green 90% green

Groenewegen, P.P., Van den Berg, A.E., Maas, J., Verheij, R., De Vries, S. (2012). Is a green residential environment better for health? If so, why? Annals of the Association of American Geographers.

Experimental research

Tyrväinen, L., Ojala, A., Korpela, K., Lanki, T., Tsunetsugu, Y., & Kagawa, T. (2014). The influence of urban green environments on stress relief measures: A field experiment. Journal of Environmental Psychology, 38, 1-9.

Positive feelings Self esteem Vitality

Before After Before After Before After

59

Systematic review

Green space

Health- Depression- Anxiety- Asthma- Birth weight- Cancer- Migraine - COPD- ADHD- etc.

Behaviour- Exercise- Social contacts- Sleep

Summary of knowledge

Physiology- NK-cells- Blood sugar- Cortisol

Psychology- Relaxation- Vitality- Mood- Attention

1 2

Phytoncides

Fractals

1. Active ingredients

- Volatile organic compounds - Antimicrobial - Increase activity NK-cells

- Natural geometry- Self-similar patterns- Easy to process

Central mechanism

Enhancement of the immune system

Key challenge: How to (re-)connect people to nature

People green“green care”

Options

Green people“greening”

65

Thank you for your attention!

Website: www.agnesvandenberg.nlEmail: [email protected] @agnes_vdberg

Gardening Its Value in Terms of

Human Health and Well-being ?

Dr Ross Cameron & Dr Alistair [email protected]

Context!

• New Species • Homo westernmanicus

• Physiology of a Hunter Gatherer

• But, lifestyle of a brick

But, living with ?

Designed for ?

For many specimens of Homo westernmanicus – Gardens provide the bridge to the natural world

Background to Gardens

• Western Society = 90% live in urban areas.• UK - 87% households have access to a garden (Gibbons et al., 2011). • Gardens = 22-36% of the total urban area (Mathieu et al., 2007).

• In UK = 1/3 to ½ of urban green space (Loram et al., 2007).

• But decreasing area dedicated to gardens - infill & new houses having smaller gardens. (Smith, 2010).

• Under-represented in the Green Infrastructure equation (Cameron et al., 2012).

Reported & Derived Benefits(e.g. Cameron, 2014)

Green Space

• Pain relief• Blood pressure• Heart rate• Less frequent illness• Improved cognitive function• Thermal comfort

Gardens• Reduced mortality • Higher bone density, less

osteoporosis• Cholesterol levels • Reduces onset of dementia

Regular gardening / gardening like activities thought to help offset • Heart disease• Ischemic stroke• Type 2 diabetes• Hypertension• Anxiety• Depression• Certain types of cancer

Gardens as Therapeutic Landscapes

• Landscapes with natural features, provide greatest restoration from stress (Ivarsson and Hagerhall, 2008) .

• Even within these – restoration promoted by presence of flowers and water – stronger correlation than presence of animals, trees, hills, natural aromas or sounds (Ogunseitan, 2005).

• Design of garden may be important in offsetting stress associated with work, commuting, family life etc., but this warrants further investigation.

Gardens & Gardening • Under-researched in Nature-Health agenda• Rel. little info on private gardens

– (more on community gardens / allotments & hort therapy)

• H&WB benefits potentially large• Heterogeneous landscapes though - in typology, but

also uses and attitudes

Gardens & Gardening • Associated with: (Clayton, 2007; Blair et al., 1991; Dallosso et al., 1988).

– Providing a form of ‘retreat’ – Interacts with nature– Place to be creative– Play and recreation– Socialise (family and friends)– Utilitarian – grow food– Physical exercise (depending on task)– Identity – self–expression

– Also though • Pressure – chores – social expectations - keep up with the Jones’

• Extent of benefits may relate to individual’s attitude to gardening.

Why More Emphasis On Gardens?4 Key Factors

1. Immediate Access

• Little organisation required.• Frequent activity & repetition

– fits into short periods of down-time in busy working lives.

• Children - easy access to nature and food education.

2. Encourage Physical Activity

Much of the immediate challenge is about moving from a sedentary to an active lifestyle

• Food gardening used to encourage physical activity in children and encourage healthy diet (Castro et al., 2013)

• Community gardeners had significantly lower BMIs for same gender syblings (−1.88 female) (−1.33 male).

• Also lower probability for overweight or obese than otherwise similar neighbours (Zick et al., 2013).

Calories burned h-1

• General gardening 239• Raking 262• Trimming shrubs 278• Weeding 278• Digging 318, • Pushing powered mower 358 (De Simone 2016)

• Compare Moderate Cycling 470-650

3. Gardens as Restorative Landscapes

• Self-absorbing – Soft fascination. Attention Restoration Theory – ‘being mentally away from the stressors’

• Repeat activity – fascination led

• Keen gardeners rarely need much motivation to garden!

• Ecological, rather than anthropogenic, view of the world.

Restorative Landscapes• Older – adults.

– Gardening more than a casual leisure pursuit - critical to their physical and psychological wellbeing. (Scott et al., 2014) .

• Allotment gardening – Single session showed significant improvement in self-esteem (P<0.05) and mood (P<0.001) (Wood et al., 2015).

• For patients suffering severe stress / mod-mild depression - significant reductions in primary healthcare visits and inpatient psychiatric care when placed on a garden orientated rehabilitation programme. (Währborg et al., 2014)

4. Creativity – Self Expression• Gardeners - control over the design / management .• Positive psychological aspects - self-esteem, feeling of

achievement and fulfilment of talent.• Form of art therapy.

Thank You !

Session 1: Strategic & academic evidence: health, wellbeing & horticulture

1000 Dr William Bird (GP & Intelligent Health)Horticulture, Health & Wellbeing: a GP’s perspective

1010 Dr Justin Varney (Public Health England)How Horticulture & PHE can work together

1020 Dr Agnes van den Berg (Environmental Psychologist)An International Perspective: Greenspace & Health

1035 Dr Ross Cameron (Sheffield University)Gardening: Value in terms of Human Health & Wellbeing

1045 Questions on Session 1