The Effect of the Built Environment on Health and Health Behaviors

1. The Effect of the Built Environment on Health and Health Behaviors PETER JAMES DEPARTMENT OF ENVIRONMENTAL HEALTH DEPARTMENT OF EPIDEMIOLOGY HARVARD SCHOOL OF PUBLIC HEALTH MAY 19, 2010

2. The Built Environment • Land-Use Patterns • Spatial distribution of human activities • Transportation Systems • Physical infrastructure and services that provide the spatial links or connectivity among activities • Design Features • Aesthetic, physical, and functional qualities of the built environment, such as the design of buildings and streetscapes, and relates to both land use patterns and the transportation system

3. Background: Built Environment and Health Low Density, Low Connectivity, Low Land Use Mix High Density, High Connectivity, High Land Use Mix

4. Measuring the Built Environment Density Land use Connectivity Duany and Plater-Zyberk. 1989. ITE Journal. 59:17-18.

5. The Built Environment and Health • Air Quality • Motor Vehicle Crashes and Motor Vehicle-Pedestrian Collisions • Physical Activity • Diet • Mental Health • Water Quantity and Quality • Disparities

6. The Common Roots of Urban Planning and Public Health • Industrial Revolution and Congestion in Cities • Infectious disease • Cholera, typhoid, yellow fever, smallpox, and tuberculosis • Deplorable housing conditions • Poor ventilation • Polluted waterways • Toxic industries in close proximity to residences

7. The Common Roots of Urban Form and Public Health • Public Health Responses • 1842: Report on the Sanitary Conditions of the Laboring Population of Great Britain • 1850: Report of the Sanitary Commission of Massachusetts • 1916: Zoning laws in New York City • 1924: Standard Zoning Enabling Act Lemuel Shattuck

8. Divergence of Public Health and Urban Planning • Germ Theory • Focus on single-agent causes of specific diseases • Economics • Investment in new communities • Transportation • Investment in the automobile • Dismantling of transit • Federal Policy • Federal Housing Administration • Veterans Affairs Mortgage Program

9. Modern Urban Form: Sprawl

10. Modern Urban Form: Sprawl • Development outpaces population growth • Low density • Rigidly separated homes, shops, and workplaces • Roads marked by large blocks and poor access • Lack of well-defined activity centers, such as downtowns • Lack of transportation choices • Relative uniformity of housing options

11. Urban Form and Transportation

12. Urban Form and Transportation • Sprawling areas exhibit • Higher rates of vehicle ownership • More vehicle-miles traveled (VMTs) per person • Lower percentages of commuters taking transit or walking to work

13. Air Quality • Urban form determines transportation patterns • Transportation patterns determine vehicle emissions • Vehicle emissions are associated with • Respiratory disease • Cardiovascular disease • Cancer • Reproductive outcomes • Premature mortality

14. Motor Vehicle Crashes and Motor Vehicle-Pedestrian Collisions • Urban form is associated with VMTs • VMTs increase time at risk to the hazards of motor vehicle travel • Urban form can dictate vehicle speeds • Long commutes can lead to fatigue and the increased risk of a crash

15. Motor Vehicle Crashes and Motor Vehicle-Pedestrian Collisions • NHTSA statistics • Less sprawling cities • New York (2.30 fatalities per 100,000 population) • San Francisco (2.45 fatalities per 100,000 population) • Portland (3.21 fatalities per 100,000 population) • More sprawling cities • Houston (10.08 fatalities per 100,000 population) • Atlanta (12.72 fatalities per 100,000 population) • Tampa (16.15 fatalities per 100,000 population) • Exceptions to this rule • Los Angeles (5.79 fatalities per 100,000 population) • Detroit (10.93 fatalities per 100,000 population)

16. Physical Activity • Obesity and overweight • Type 2 diabetes mellitus, gallbladder disease, coronary heart disease, high blood cholesterol level, high blood pressure, osteoarthritis, sleep apnea, stroke, liver disease, musculoskeletal disease, reproductive function, some forms of cancer, and mortality • Sedentary lifestyle • Depression, hypertension, type 2 diabetes mellitus, colon cancer, osteoarthritis, osteoporosis, coronary heart disease, and all-cause mortality

17. Physical Activity • Three factors of urban form that may determine physical activity • Transportation systems connect places and determine the feasibility of using different modes of transport • Land use patterns determine the proximity of destinations and thereby the feasibility of walking or cycling • Urban design characteristics alter individual perception of whether the environment is desirable or inviting for physical activity

18. Physical Activity • Sprawling communities associated with • Lower rates of physical activity • Higher body mass index (BMI) • Higher prevalence of hypertension • Overweight and obesity associated with • Streets with no sidewalks or sidewalks on one side only • Lower residential density • Lower land-use mix • Lower street connectivity • Majority of studies have small sample sizes and cover small geographic ranges

19. Diet • The presence or density of food retailers and restaurants is thought to be related to diet • Supermarkets provide a variety of affordable healthy foods, such as fresh fruits and vegetables and whole grains • Convenience stores supply highly processed foods rather than fresh foods • Fast food outlets offer large portion sizes and energy-dense foods • Growing literature shows diet correlated with the presence or density of food retailers and restaurants • Density of supermarkets associated with higher fruit and vegetable consumption and lower obesity prevalence

20. Mental Health • Urban form is associated with VMTs • Higher VMTs are associated with higher levels of stress • Known stress responses due to driving and commuting • Chronic stress from driving • Cardiovascular disease • Musculoskeletal symptoms

21. Mental Health • Depression • Limits on physical activity may deny a treatment for depression • Low density leads to social isolation, which leads to depression • Monotony and aesthetic qualities of sprawl may be root of depression • Road rage • Events in which an angry or impatient driver tries to kill or injure another driver after a traffic dispute • Risk factors are traffic volume and traffic distance

22. Water Quantity and Quality • Water quality • Biological pollutants • Hepatitis A or E • Coxsackie viruses, Adenoviruses, and Norwalk viruses • Pathogenic bacteria Helicobacter or Legionella. • Parasites Cryptosporidium and Giardia • Chemical pollutants • Pesticides, metals, nitrates, radionuclides, and organic chemicals • Disinfection byproducts, such as iodinated trihalomethanes

23. Water Quantity and Quality • Decreasing density, proximity, and connectivity require more impervious paved surface per capita • Decreases the ability of rainfall to recharge groundwater aquifers • High velocity runoff increases erosion and speeds the transfer of pollutants into the water supply • Storm surges overload sewage treatment plants and discharge excess untreated water directly into adjacent bodies of water, leading to bacterial contamination • Modeling has shown that higher density development reduces peak flows and total runoff volume • Higher rates of motor vehicle use leads to higher levels of pollutants in runoff

24. Disparities • Low SES populations • More likely to • rely on walking and public transit to commute • live near high-speed traffic areas with fewer clearly marked and safe crossing routes • Pedestrian fatalities • Atlanta pedestrian fatality rates during 1994-1998: 9.74 for Hispanics, 3.85 for African Americans, and 1.64 for Whites • Hispanics: 8% of the population of the Virginia suburbs of Washington, DC; 21% of pedestrian fatalities

25. Disparities • Older and Disabled Persons • Limited mobility • Reliance on automobiles • Fewer transit options • Social isolation  cognitive decline

26. Conclusions • Public health historically linked to urban planning • The built environment is associated with • Air pollution • Physical activity • Diet • Water quality and quantity • Motor vehicle crashes • Pedestrian injuries and fatalities • Mental health • Health disparities

27. Significance The health behaviors and health outcomes discussed are major contributors to morbidity and mortality in the US The built environment is a ubiquitous and modifiable exposure Built environment studies generally have small sample sizes, cover small geographic ranges, and are cross-sectional

28. Research Needs • Improved epidemiological data • Multilevel modeling using geographic information systems • Longitudinal study designs • Better spatial resolution in measurement of urban form variables

29. My Research • In order to close some of these research gaps, we aim to analyze prospective data to understand multiple measures of the built environment and their effect on: • Physical activity • Diet • Body mass index • Cardiovascular disease • Total mortality

30. Conceptual model for the effects of the built environment on physical activity and obesity Street connectivity Residential or population density Access to physical activity resources Physical activity environment Physical activity Access, density, and diversity of destinations Obesity CVD / Mortality Supermarkets and grocery stores Access/density food retail Dietary intake Food environment Convenience stores Access/density food service Sit-down restaurants * Food retail and food service facilities could be also be physical activity destinations. Fast-food restaurants

31. Specific Aim 1 To assess the association between the county-level built environment and changes in physical activity and body mass index in the Nurses’ Health Study I and II from 1986-2006

32. NHS NHS II Study Population NHS NHS II Nurses’ Health Studies I and II Addresses geocoded every two years from 1986 until 2006 Combined over 200,000 participants

33. Exposure • County Sprawl Index created by the National Center for Smart Growth • Based on 2000 Census measures of residential density and street accessibility • Linked to participants from geocoded address at each questionnaire year

34. Outcome Continuous body mass index from self-reported weight at each questionnaire divided by height as reported in the initial questionnaire squared (kg/m2) Continuous physical activity from questions about recreational or leisure time physical activity during the past year and calculated in metabolic equivalent hours per-week

35. Cross-sectional analysis of County Sprawl Index and BMI and Physical Activity in 2000

36. Statistical Analysis Model for “Stayers” Multi-level longitudinal model with random intercepts for individual and county Yijk=β0+ β1Timeijk+ β2Individualjk+β3Sprawlk+ β4Timeijk*Sprawlk+β5X5…+(u0j+ v0k+e0ijk) [e0ijk]~N(0, σ2e0) [u0j]~N(0, σ2u0) [v0k]~N(0, σ2v0) Where: i denotes observations j denotes individuals k denotes county

37. Statistical Analysis • Model for “Movers” • ∆Yt, t+1=β1∆Sprawlt, t+1+ β2∆SESt, t+1+ β3X3t, t+1…+e • Where ∆Yt, t+1 is the change in BMI or physical activity from pre-move questionnaire to post-move, ∆Sprawlt, t+1 is the change in county sprawl index from pre-move to post-move, ∆SESt, t+1 is the change in socioeconomic status from pre-move to post-move, and other time-variant covariates are included in X3…

38. Statistical Analysis • Potential confounders • Race • Diabetes • Smoking status • Individual level socioeconomic status • Census tract-level data for two socioeconomic status variables • Median household income • Median household value

39. Specific Aim 2 To examine the association between exposure to residence-level built environment features and particulate air pollution with incident nonfatal myocardial infarction, fatal coronary heart disease, and all-cause mortality in the Nurses’ Health Study I and II from 1988-2006

40. Exposure Assessment: Residence-Level Built Environment • Residential density • Census tract density from US Census data • Land use mix • Location density from InfoUSA • Street connectivity • Intersection density from StreetMap USA

41. Street Network Buffers 800m road network buffers around geocoded home addresses, excluding interstates and ramps 800m is the upper limit of what individuals are willing to walk, based on urban planning literature Non-interstate roads are generally walkable; however, we did not specifically measure micro-environment features, such as sidewalk availability, crosswalks, etc.

42. Street Network Buffers Polygons created radiating from residence 800m via local road network with 50m on each side of the road Estimates of the area that is 800m walking distance from each residence via the local road network

43. Residential Density Area weighted sum for network buffers based on intersecting census tracts from US 2000 Census data

44. Residential Density Area weighted sum for network buffers based on intersecting census tracts from US 2000 Census data

45. Land Use Mix Location Count: Counts of businesses within 800m network buffers based on stores, facilities, and services from 2006 InfoUSA spatial database on businesses, which include grocery stores, restaurants, banks, etc.

46. Land Use Mix Location Count: Counts of businesses within 800m network buffers based on stores, facilities, and services from 2006 InfoUSA spatial database on businesses, which include grocery stores, restaurants, banks, etc.

47. Street Connectivity Intersection Count: Number of 3-way or greater intersections per square km within each network buffer Interstates and ramps will be excluded

48. Street Connectivity Intersection Count: Number of 3-way or greater intersections per square km within each network buffer Interstates and ramps will be excluded

49. Exposure Assessment: Air Pollution • 12-month average exposure based on existing NHS PM10 model • Predicts monthly outdoor concentrations based on residence • Generalized additive mixed model uses air pollution monitoring data and penalized regression terms of GIS-based and meteorologic covariates • Covariates include: population density (at tract and county level); distance to road; elevation; urban land use in a 1-km radius; point- and area-source PM10 emissions; wind speed; and precipitation

50. Outcome • Mortality • Family or postal authorities • National Death Index • Nonfatal myocardial infarctions • Biennial questionnaires and confirmed through medical record review • Fatal CHD • Confirmed by death certificate, hospital records, or autopsy • Only cases indicated as definitely or probably confirmed were counted