The Science & Art of Healthy Built Environments - CPPW Action Institute Washington DC June 2010

1. (Walk audits at the Atlanta kick-off meeting.) The Science & Art of Healthy Built Environments-CPPWAction InstituteWashington DCJune 2010 “We few, we happy few, we band of brothers” and sisters . . .

2. Topics for consideration: • Some perspective . . . • A brief rant. • A question of priorities, and 5 recommendations. • Stickier community designs. • Putting the MAPPS strategies together. • Why it really matters!

3. Youthful recollections

4. Not just my idea . . . 30-Nov-2009 The Australian, 14-Oct-2009

5. The rant: America’s looming chronic disease apocalypse . . . US “Obesity Epidemic”Ogden et. al. (JAMA 288, 14; Oct. 2002)

6. Diabetes Prevention Program(DPP; New.Eng.J.Med., April 2002) Compared three treatments for nationwide cohort (3,000+) at risk for developing diabetes (elevated fasting glucose). • Control: Standard exercise and nutrition counseling; placebo. • Standard plus drug treatment: Metformin • Intensive lifestyle change: Nutritional training, 150 min./week physical activity.

7. Diabetes Risk Reduction(Diabetes Prevention Program; NEJM, April 2002)

8. My Rant:Change the conversation.It’s notjust an obesity epidemic. At the core it is epidemics of physical inactivity and poor nutrition.

9. Recommendation 1: Think about scale & effectiveness. Ask the simple question: in how many people is this likely to actually change behavior?

10. The bad news in just three numbers: Minutes of daily physical activity recommended by national guidelines. % of American adults who meet the S.G. recommendation (thru LTPA). ,000 Estimated annual deaths in America due to physical inactivity & poor nutrition. (2nd only to tobacco.) 30 25 365

11. Surgeon General’s Report 1996 Physical Activity Guidelines 2008 www.health.gov/paguidelines • 150 minutes/week of moderate physical activity; more is better. • Any activity is better than none. • Can be broken up. • 300 min/week for children. • Reduced risk for CVD, diabetes, osteoporosis, dementia in old age, clinical depression, a growing list of cancers, obesity. Getting some exercise, or just getting somewhere in Providence?

12. Leisure Time Physical Activity in the US (MMWR: 50(09), 166-9; 54(39), 991-4]

13. Why is it so stubborn? I believe it’s related to the stickiness problem.

14. Exercise ParticipationEffect of Short Bouts, Home Treadmills(Jakicic et.al., JAMA 282, 16) ?

15. Exercise ParticipationEffect of Short Bouts, Home Treadmills(Jakicic et.al., JAMA 282, 16)

16. Self-help vs. CommercialWeight Loss Programs(Heshka et.al., JAMA 289, 14; April 9, 2003)

17. Recommendation 2: Go for breadth—not just “exercise” for the actively inclined. We need increases in routine, daily physical activity for everyone.

18. Recommendation 2 (H.E.): Go for breadth—not just getting people onto “diets.” We need increases in routine, daily healthy eating for everyone.

19. Pedometer-based “lifestyle” activity promotion: • Measure steps all day. • Determine your average daily steps. • Increase by only 10%-20% a week. • Keep gradually increasing . . . Key to Success: Keep a record!

20. Energy ExpenditureLifestyle vs. Structured Activity(Dunn et.al., JAMA 281, 4)

21. Social Ecology ModelDeterminants of behavior changeSallis, Owen, “Physical Activity and Behavioral Medicine.” • Individual (readiness, efficacy) • Interpersonal (family, friends) • Institutional (school, work, HMO) • Community (networks, local gov’t) • Public Policy (transport, land use)

22. Tobacco – Education, kids, taxes, 2nd hand smoke policies/bans. Seat belts, child safety restraints – Media, training, laws, enforcement. Recycling – Kids, facilities, fees. Water & sewer – Education, ordinance & design requirements, inspection/enforcement procedures. Socio-ecological successes?

23. vs.

24. The “healthy” trip decision hierarchy*: *Nearly 25% of all trips are one mile or less; roughly 40% are two miles or less! (Nat’l Household Transportation Survey) Walk Bike Transit Drive

25. Recommendation 3: We have to make active living & healthy eating the easier choices - actually safer, more convenient, less costly, and even more fun than the alternatives.

26. The “Toxic” Environment? (Kelly Brownell, Yale) Middletown, RI

27. Grapevine TX Denton TX So, what does the research say matters? Marshalltown, IA Destinations within walk, bike, & transit distance? Sidewalks, trails, bike lanes, safe crossings? Inviting settings & sites for bikes, peds, transit? Safe & accessible for all ages, incomes, abilities? www.thecommunityguide.org CDC Guide to Community Preventive Services

28. Or in Planner-Speak: Portland, ME Land use mix. Network of ped, bike, & transit facilities. Functional site design & details. Safety & universal access.

29. Schools, services near housing. Schools 1. Land use. E.g. shopping, post office, library, . . . Compact neighborhoods Housing above retail below. & shared open space. Mixed use, multi-family. Pinellas Trail

30. Laramie In other words, create & sustain village centers. Mix uses: keep where we live, work, shop, play, learn, pray . . . closer together! “It’s not a neighbor-hood if you don’t have a corner store” (Indianapolis)

31. 2. Network encourages active travel with: • Presence of sidewalks, paths, bicycle lanes. • Shorter blocks, connect cul-de-sacs, more intersections. • Access to trail, park, greenway, transit. E.g., Kingsport, TN Greenway Louisville

32. Transit riders are physically active. Besser, Dannenberg, Amer. J. Prev. Med., 29 (4), Nov. 2005. Just during the daily walk to transit: • Half of transit riders walk at least 19 mins. • 29% get at least 30 mins. of activity. • Minorities, poor (income <$15k/yr.), denser urban dwellers more likely to get 30+ mins./day. Appleton WI

33. 3. Site design: Market Po Which setting is more appealing for travel on foot and by bike?

34. Site design?Research & practice suggest: Pedestrian friendly access; buildings are near the sidewalk, not set back. Trees, benches, water, aesthetics, lighting, scale. Details: bike parking, open space, plantings, materials.

35. 4. Safety. Median islands Engineering can dramatically improve safety. Increasing pedestrian and bike trips decreases overall accident & fatality rates. Roundabout (Neenah, WI) Curb extensions (Jacobsen P, Injury Prevention, 2003; 9:205-209.)

36. % of Total Trips Taken by Bicycle. Pucher J, Transport Reviews, 2008 (various sources).

37. Obesity Rates, Developed Countries Organization for Economic Cooperation & Development; www.oecd.org

38. “But what about rural areas . . . ?” Suburbanization of AmericaUS population shift, 1950-1996(after Bowling Alone, R. Putnam, 2000) • Suburbia is steadily consuming the landscape . . .

39. “Rural” housing in SW Illinois? 2. Rural areas are where you can affect the shape of development before it’s done!

40. Community design & nutrition? Community gardens (near schools, parks, senior housing); conserving farmlands; Community Supported Agriculture. Olathe, KS Regulate fast food, drive-through locations. Farmer’s markets, green grocers.

41. Community gardens & farm markets can help overcome food deserts, but they’re not enough. East St. Louis Need neighborhood grocers as well (co-ops, CSA’s, whatever it takes).

42. BMI, Fast Food Outlets & Car Ownership Inagami S, et.al., BMI, Neighborhood Fast Food and Restaurant Concentration and Car Ownership, Journal of Urban Health, Vol 86 (5). Estimated additional weight (lbs.) Density of fast food restaurants (Reference condition: No car, low density of fast food restaurants.)

43. BMI, Fast Food Outlets & Car Ownership Inagami S, et.al., BMI, Neighborhood Fast Food and Restaurant Concentration and Car Ownership, Journal of Urban Health, Vol 86 (5). Estimated additional weight (lbs.) Density of fast food restaurants (Reference condition: No car, low density of fast food restaurants.)

44. BMI, Fast Food Outlets & Car Ownership Inagami S, et.al., BMI, Neighborhood Fast Food and Restaurant Concentration and Car Ownership, Journal of Urban Health, Vol 86 (5). Estimated additional weight (lbs.) Density of fast food restaurants (Reference condition: No car, low density of fast food restaurants.)

45. Recommendation 4:Both the built and social environments of the community matter, so work on improving them. Start by helping people realize what “sticks” and what doesn’t.

46. All the “health” benefits: • Education • Increased safety. • Reduced transportation costs and infrastructure. • More community engagement; schools as neighborhood centers. • Environmental • Reduced traffic; air, water, & noise pollution. • Conserved open space, agricultural land. • Social • Equitable transportation. • More personal connections. Knoxville, TN • Safety • Kids, elderly mobility. • Crime deterrent. Vernon, CT

47. Economic: • Residents shop locally; more stable tax base. • Healthy employees, low turnover, happy employers. • Healthy housing values • (NAHB & NAR surveys). Marshalltown, IA Or more simply: < Which generates more tax revenue in the long run? ^

48. Rec. #5: MAPPS strategy framework • Media: Educate & build awareness, encourage behavior change. • Access: Create “stickier” environments. • Point of decision prompts: Promote, “nudge” toward the healthy, active choice. • Price: Both ways (healthy choice affordable, unhealthy choices more expensive). • Social support: Shift social norms (think smoking); inactivity, crummy eating the exception not the rule. (The oatmeal syndrome.)

49. Media: Washington DC Free Ride promotion • On the surface, a short term behavior change promotion: Get people to do more active commuting. • At the core: Get employers to make sticky changes, subsidizing employee transit, flex time, lockers & showers. >

50. Media: Topeka, KS PHC program has focused on policy. • Jim Ogle, PHC team member, has modeled the change (WIBW): • Dec. ‘08 – 3,700 steps/day • Sep. ‘09 – 15,000+ steps/day!!!!!