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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!
US “Obesity Epidemic”Ogden et. al. (JAMA 288, 14; Oct. 2002)
10
15
20
25
30
35
1960 1970 1980 1990 2000 2010
% O
bese
(BM
I>30
)
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)
0.31
0.58
0%
20%
40%
60%
80%
100%
Metformin Lifestyle
Relative to Control Group (standard intervention)
% R
ed
uc
tio
n o
f R
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.)
25
365
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]
10
20
30
40
50
1985 1990 1995 2000 2005
% o
f U
S P
op
ula
tio
n
Inactive Sufficiently Active
Exercise ParticipationEffect of Short Bouts, Home Treadmills
(Jakicic et.al., JAMA 282, 16)
60
120
180
240
0 6 12 18
months
Ex
erc
ise
(m
in/w
ee
k)
LB
SB
SBT
?
Exercise ParticipationEffect of Short Bouts, Home Treadmills
(Jakicic et.al., JAMA 282, 16)
60
120
180
240
0 6 12 18
months
Ex
erc
ise
(m
in/w
ee
k)
LB
SB
SBT
Self-help vs. CommercialWeight Loss Programs
(Heshka et.al., JAMA 289, 14; April 9, 2003)
-7
-6
-5
-4
-3
-2
-1
0
0 6 12 18 24months
Wei
gh
t C
ha
ng
e, k
g
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)
32
33
34
35
0 6 12 18 24months
En
erg
y E
xpen
dit
ure
(k
cal/k
g/d
ay)
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*:
Walk
BikeTransit
Drive
*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.
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.)
0
5
10
15
20
25
30
US
UK
Aus
tral
iaC
anad
aIr
elan
dIta
lyFr
ance
Nor
way
Aus
tria
Sw
itzer
land
Bel
gium
Ger
man
yS
wed
enFi
nlan
dD
enm
ark
Net
hrln
ds
% a
du
lts
BM
I>30
% of Total Trips Taken by Bicycle.Pucher J, Transport Reviews, 2008 (various sources).
0
5
10
15
20
25
30
35
US
UK
Aus
tral
iaC
anad
aIr
elan
dIta
lyFr
ance
Nor
way
Aus
tria
Sw
itzer
land
Bel
gium
Ger
man
yS
wed
enFi
nlan
dD
enm
ark
Net
hrln
ds
% a
du
lts
BM
I>30
Obesity Rates, Developed CountriesOrganization for Economic Cooperation & Development; www.oecd.org
Suburbanization of AmericaUS population shift, 1950-1996
(after Bowling Alone, R. Putnam, 2000)
10
20
30
40
50
1950 1960 1970 1980 1990 2000
year
% o
f T
ota
l Po
pu
lati
on
Suburb
Urban
Rural
“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
0
2
4
6
8
10
12
14
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.)
0
2
4
6
8
10
12
14
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.)
0
2
4
6
8
10
12
14
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.)
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!!!
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).
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.
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.
