Mark.fenton@verizon.net The Science & Art of Healthy Built Environments - CPPW Action Institute...

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mark.fenton@verizon.net

The Science & Art of Healthy

Built Environments

CPPWAction Institute

Washington DCJune 2010

“We few, we happy few,

we band of brothers” and

sisters . . .

(Walk audits at the

Atlanta kick-off meeting.)

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!

Youthful recollections

Not just my idea . . .

The Australian, 14-Oct-2009

30-Nov-2009

US “Obesity Epidemic”Ogden et. al. (JAMA 288, 14; Oct. 2002)

1960 1970 1980 1990 2000 2010

The rant: America’s looming chronic disease apocalypse . . .

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).

1. Control: Standard exercise and nutrition counseling; placebo.

2. Standard plus drug treatment: Metformin

3. Intensive lifestyle change: Nutritional training, 150 min./week physical activity.

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

Metformin Lifestyle

Relative to Control Group (standard intervention)

isk Risk Reduction

My Rant:Change the conversation. It’s not just an obesity epidemic. At the core it is epidemics of physical inactivity and poor

nutrition.

Recommendation 1:Think about scale &

effectiveness. Ask the simple question: in how many people is this likely to

actually change behavior?

The bad news in just three numbers:

30 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.)

Surgeon General’s Report 1996 Physical Activity Guidelines 2008

• 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?

www.health.gov/paguidelines

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

1985 1990 1995 2000 2005

Inactive Sufficiently Active

Why is it so stubborn?

I believe it’s related to the stickiness problem.

Exercise ParticipationEffect of Short Bouts, Home Treadmills

(Jakicic et.al., JAMA 282, 16)

0 6 12 18

months

Exercise ParticipationEffect of Short Bouts, Home Treadmills

(Jakicic et.al., JAMA 282, 16)

0 6 12 18

months

Self-help vs. CommercialWeight Loss Programs

(Heshka et.al., JAMA 289, 14; April 9, 2003)

0 6 12 18 24months

Self-help

Commercial

Recommendation 2:Go for breadth—not just

“exercise” for the actively inclined. We need increases

in routine, daily physical activity for everyone.

Recommendation 2 (H.E.):Go for breadth—not just

getting people onto “diets.” We need increases in routine,

daily healthy eating for everyone.

Pedometer-based “lifestyle” activity promotion:

• Measure steps all day.• Determine your

average daily steps. • Increase by only10%-20% a week.• Keep gradually

increasing . . .

Key to Success: Keep a record!

Energy ExpenditureLifestyle vs. Structured Activity

(Dunn et.al., JAMA 281, 4)

0 6 12 18 24months

Lifestyle

Structured

Social Ecology ModelDeterminants of behavior change

Sallis, 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)

Socio-ecological successes?

• 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.

The “healthy” trip decision hierarchy*:

BikeTransit

*Nearly 25% of all trips are one mile or less; roughly

40% are two miles or less!(Nat’l Household

Transportation Survey)

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.

The “Toxic” Environment?(Kelly Brownell, Yale)

Middletown, RI

So, what does the research say matters?

1. Destinations within walk, bike, & transit distance?

2. Sidewalks, trails, bike lanes, safe crossings?

3. Inviting settings & sites for bikes, peds, transit?

4. Safe & accessible for all ages, incomes, abilities?

Denton TX

www.thecommunityguide.orgCDC Guide to Community Preventive Services

Grapevine TX

Marshalltown, IA

Or in Planner-Speak:

• Land use mix.• Network of ped,

bike, & transit facilities.

• Functional site design & details.

• Safety & universal access.

Portland, ME

Compact neighborhoods

1. Land use. Schools, services near housing.

Mixed use,

multi-family.

& shared open space.

E.g. shopping, post office, library, . . .

Housing above retail

below.

Schools

Pinellas Trail

In other words, create & sustain village centers.

Laramie

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)

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

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

3. Site design:

Market Po

Which setting is more appealing

for travel on foot and by bike?

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.

4. Safety. • Engineering can dramatically improve safety.

• Increasing pedestrian and bike trips decreases overall accident & fatality rates.

Curb extensions

Median islands

Roundabout (Neenah, WI)

(Jacobsen P, Injury Prevention, 2003; 9:205-209.)

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

Obesity Rates, Developed CountriesOrganization for Economic Cooperation & Development; www.oecd.org

Suburbanization of AmericaUS population shift, 1950-1996

(after Bowling Alone, R. Putnam, 2000)

1950 1960 1970 1980 1990 2000

Suburb

“But what about rural areas . . . ?”

1. Suburbia is steadily consuming the landscape . . .

2. Rural areas are where you can

affect the shape of development

before it’s done!

“Rural” housing in SW Illinois?

Community design & nutrition?

Farmer’s markets, green grocers.

Community gardens (near schools, parks, senior housing); conserving

farmlands; Community Supported Agriculture. Regulate fast food, drive-

through locations.

Olathe, KS

Community gardens & farm markets can help overcome food deserts, but they’re not enough.

Need neighborhood grocers as well (co-ops, CSA’s, whatever it takes).

East St. Louis

No Car Owns Car

Low FF

High FF

Low FF

High FF

BMI, Fast Food Outlets & Car OwnershipInagami 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.)

No Car Owns Car

Low FF

High FF

Low FF

High FF

weight (lbs.)

restaurants

No Car Owns Car

Low FF

High FF

Low FF

High FF

weight (lbs.)

restaurants

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.

All the “health” benefits:Environmental

• Reduced traffic; air, water, & noise pollution.• Conserved open space, agricultural land.

Safety• Kids, elderly mobility.• Crime deterrent.

Social• Equitable transportation.• More personal connections.

Education• Increased safety.• Reduced transportation costs and infrastructure.• More community engagement; schools as neighborhood centers.

Knoxville, TN

Vernon, CT

Economic:• Residents shop locally; more stable tax base.• Healthy employees, low turnover, happy employers.• Healthy housing values(NAHB & NAR surveys).

Or more simply:< Which generates more tax revenue in the long run? ^

Marshalltown, IA

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.)

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. >

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!!!!!

Topeka, KS PHC team:

• Focused on supporting the city’s “Fix the Streets” campaign – policy level change!

• Half-cent sales tax increment for roadway repairs.

• Then targeted Complete Streets policy statement by city council.

• Passed in Nov. 2009!!!

mark.fenton@verizon.netwww.completestreets.org

Accommodate all users:• Pedestrians• Bicyclists• Transit• Motor vehiclesDesign speed = posted speed.Few exceptions, clearly defined.Expand the hierarchy.

Access: Complete Streets Policy

The real phases of CS policy implementation.

1. Passage of a policy resolution or executive order.

2. Adoption of DPW/engineering policy.3. Adoption of detailed roadway design

standards or guidelines. (Pirate’s code?)

4. Engineering practice (staff, consultants) actually entails routine inclusion of ped/bike/transit consideration in absolutely every project (including routine maintenance).

E.g. Design guidelines affect the built environment for years to come.

Lane re-alignments• Often called road diets,

being seen more often.

• Can reduce collisions & severity.

• Dramatically improves performance for pedestrians & cyclists.

Urbana, IL; before & after.

In East St. Louis, maybe some paint can help?

State Street (to Main Street, Belleville)

• Site requirements: Max. setbacks & curb-cuts; limit drive-throughs.

• Subdivision rules: Curbs, sidewalks, road widths.

Access: Change the rules & ordinances.

• Zoning codes: Mixed uses, accessory dwellings, density bonuses.

Point of decision prompts:

E.g. Stairway use efforts:• Open locked doors; signs.• Clean & paint, art, music.• Footprints, encouragement.• 3%-10% increase in stair use.

Point of decision information:Transit arrival info.

Social support: E.g. Louisville, KY Pedestrian Planning & Summit

Series of community based workshops w/ walkabouts: School, community center, seniors, disabilities . . .

1. Learn; 2. Walk; 3. Work; 4. Plan & detail.

Louisville Plan Kick-off Event w/:• Mayor Abramson• Health Dir. Dr. Troutman• Sewer Dist. Dir. Schardein

Why the walkabouts?• Inspiration – get engaged• Education – learn how• Practical planning, design

E.g. Bus tours with key partners . . .

Hockomock Y, southeast MA.

Lexington, KY tour w/ developers, planners, elected officials.

Safe Routes to School approach.

• Social support. Walking school busses, bicycle trains, safety education, promotion.

• Access. Construct remote drop-off area at park; relocate bus pick/drop.

• Point of decision. Improve trail through park; signs.

*Begin evaluating today; figure out where kids come from, how, & why!

Columbia, MO

www.saferoutesinfo.org

Let’s really talk about “price:”• Economic stimulus $.

Which infrastructure?

• Transit funding. Rail, bus, van & car pool.

• Congestion charges. Auto disincentive.

• Tolls, parking, gas taxes? Carrot & stick.

• Insurance rewards for active commuting.

• 3rd quarter 2008. Auto miles 4.6% Transit use 6.5%

www.apta.org

www.fhwa.dot.govwww.apta.com

US Total Vehicle Miles Traveled

(VMT); moving 12-month total, by year

2007-2008VMT: - 3.6%Transit use: + 4%

Related to fuel prices, economic

slow down.

Omaha, NE health coalitionHiring an Active

Transportation Coordinator:

• First two years half-funded by Alegent Health (private sector partner).• Metropolitan Area Planning Association also funding.• Housed in City of Omaha Planning Department.

(True systems level change.)

Healthy Eating tactics?

Policy: Overcoming food deserts through zoning & tax incentives to

encourage neighborhood groceries.

Access, price: Subsidized rotating farmers markets (target

at-risk neighborhoods).

PoD: Community gardens at schools.

Why care about stickiness & active community design?

• The inactivity epidemic; our kids may pay!• ~4,000 pedestrian, ~40,000 motor vehicle,

~400,000 sedentary-related deaths/year.• Smog alerts, over an hour of average commute

time/day, traffic congestion and costs.• OPEC; drilling in ANWR; oil wars in Mid-east.• More eyes on the street, less crime.• Shopping locally, healthier housing values.• Higher employee retention, higher productivity,

lower health care costs.

Keys to success:

• Policy, systems, and environmental change means increasing stickiness.

• Focus not on people reached and messages heard; focus ultimately on behaviors changed.

• Reach out to and fully engage (on their terms) partners in: education, planning, engineering, economic development, the business & development communities.

Mark.fenton@verizon.net The Science & Art of Healthy Built Environments - CPPW Action Institute...

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