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Research?
Can the built environment make us fat?by fostering unhealthy lifestyles such as physical inactivity, automobile dependency, and poor diet?
? THE QUESTION
PHYSICAL Activity OBESITY
BUILT ENVIRONMENT
Quality of LifeCardiovascular DiseasesDiabetesRespiratory DiseasesCancersDepressionAging
TransportationHousehold
Leisure & Recreation Work-related
DensityLand UseTransportation InfrastructureUrban & Architectural DesignAestheticsSafety
Our Behaviors… 60+% of US adults (BRFSS) and 60+% of global population (WHO) are not regularly active. In the US, active transport (walk & bike) to school among 5 to 18 years reduced from 42% in 1969 to 16% in 2001 (CDC).
Walking to school
http://www.cdc.gov/nccdphp/dnpa/kidswalk/then_and_now.htm
Active Transport to SchoolAmong Youth 5 to 18 Years of Age
Walking-Friendly Walking-HostileLocation Center PeripheryDistance 28% within ½ mile 13% within ½ mileAccessibility All directions Only 2 access pointsFrontage Streets Local streets Highway and arterialsSidewalk Complete with trees Incomplete with no trees
Street patternGrid-like with small blocks
Grid-like and cul-de-sacs with super blocks
Land Use Primarily residential Commercial and office uses with large parking lots
Drive-through voting draws early voters in Southern California
(AP Photo/Mark Avery, Oct. 21, 2008)
Los Angeles: The architecture of four ecologies (Banham, 1971)
AP Photo/Mark Avery, Oct. 21, 2008)
http://www.treehugger.com/files/2008/10/bike-thru-banking.php
Empirical EvidenceThe Link Between Built Environment and
Lifestyle Physical Activity
A Few Findings on Health Benefits of Walking and Biking
• Sesso and colleagues (1999) found that walking more than 10 blocks everyday resulted in a 33 % reduced cardiovascular disease risk.
• LaCroix et al (1996) observed that the increased hours of walking is related with reduced rate of cardiovascular disease hospitalization.
• Oja and colleagues (1998) reported that daily walking and bicycling to work improves the cardio-respiratory and metabolic fitness of previously inactive adults and health beneficial.
• Pollock et al (1978) also concluded that moderate to high energy cost activities such as running, jogging, walking, and bicycling, show a significant increase in cardio-respiratory fitness.
A Few Findings on Health Benefits of Walking and Biking
Lifestyle interventions (i.e., walking and bicycling), compared to structured intervention (i.e., exercise program and health club activities), are
– more likely to induce long-term lifestyle changes
– effective for currently sedentary people
– more cost effective
(i.e., Dunn et al., 1999; Owen and Bauman, 1992; Sevick et al., 2000)
Correlates of Overall or Recreational Physical Activity
Objective Measures:– Geographic location (levels of
urbanization, coastal location, etc.)
– Age of the neighborhood/housing (neighborhood design)
– Density– Destination (physical activity
facilities, shops, etc.)
– Streets (sidewalks, safety, route quality and barriers)
Lee C and Moudon AV (2004). Physical activity and environment research in the health field: Implications for urban and transportation planning practice and research. Journal of Planning Literature, 19(2), 147-181.
Perceived Measures: Land use mix Accessibility Convenience Safety Route quality Barriers (distance, etc.) Aesthetic/visual
quality Etc.
Correlates of Transportation Behaviors (mode choice, VMT, non-motorized mode use, etc.)
• Density• Land use mix• Infrastructure design• Transit service• Neighborhood design• Safety• Topography• Visual quality • Etc.
Environments that support Walking
The 3Ds+R–Destination
–Distance
–Density
–Route
Lee C, Moudon AV (2006). 3Ds+R: Land use and urban form correlates of walking. Transportation Research D, 11(3), 204-215.
#
#
Origin Destination
Destination
R3
R2
Area
Area
R1
How far do people walk?
Walking to (n=608)
Number
Walked
Minutes Taken
Estimated Kilometer
s
Estimated Miles
Grocery Stores 280 12.36 0.99 0.62
Retail-Service Facilities (excluding Grocery Stores) 331 12.98 1.04 0.65
Walking or Jogging Trails 114 8.38 0.67 0.42
Parks, Areas near Lakes, Creeks, or Waterways 149 10.25 0.82 0.51
Gyms or Fitness Centers 16 8.69 0.70 0.43
Seattle, WBC Survey
Younger Adults
N=213Older Adults
N=65
Grocery store* Rank % Rank %Non-fast food restaurant 1 46.0 2 43.1Café or coffee shop 2 31.0 4 27.7Convenience store 3 30.5 7 21.5Drug store 4 29.1 1 60.0Bank 5 28.6 3 33.8Post office 6 22.5 4 27.7Video store 7 18.3 14 7.7Clothing store 8 16.0 6 23.1Book store 9 15.0 15 15.4Fast food restaurant 10 15.0 14 6.2Library 11 13.1 8 18.5Hardware store 12 7.5 11 12.3Theaters and movie theater 13 7.5 12 10.8Dry cleaners 14 6.1 12 10.8Religious institution 15 3.8 9 15.4
Where people walk to? Seattle
Seattle, WBC Survey
Where people walk to? El Cenizo, TX
Destinations (n=89) N Percent
Food Stores & Restaurants
Grocery store 41 46.1%Convenience Store 3 3.4%Fast Food restaurant 2 2.2%Non Fast Food restaurant 1 1.1%
Other StoresHardware Store 4 4.5%Salon/ Barber Shop 3 3.4%Bingo / Party Supply 2 2.2%Garage Sale 4 4.5%
Services
Post Office/Mailbox / Postal services 40 44.9%Community Center 38 42.7%Bus / Transit Stop 30 33.7%Elementary School 28 31.5%Religious Institution 16 18.0%Day Care 1 1.1%
Where do people go for “recreational” walking?
Younger Adults
N=311Older Adults
N=127
Rank % Rank %
Street 1 63.0 1 66.9Park 2 52.1 2 43.3Trail 3 34.7 3 25.2Gym 4 14.1 4 10.2Mall 5 4.2 5 7.9
Seattle, WBC Survey
What are the barriers to walking?El Cenizo, TX
N=89Personal
Environ mental
No. % No. %1. Unattended dogs 33 37.1%
2. No parks or recreations places 31 34.8%
3. No benches or places to rest 27 30.3%
4. No interesting places to walk 25 28.1%
5. No trees or shade 24 27.0%
6. Distances to places are too great 19 21.4%
6. No sidewalks or no continuous sidewalks 19 21.4%
6. No safe places to walk nearby 19 21.4%
9. No interesting architecture 17 19.1%
10. No crosswalks or pedestrian signals 15 16.9%
10. No shopping locations nearby 15 16.9%
12. Not enough lighting at night 14 15.7%
13. Lack of time 13 14.6%
14. No walking paths or trails nearby 12 13.5%
15. Fear of being robbed/ attack/ assaulted 11 12.4%
16. Traffic is traveling too fast on roads I need to walk along 10 11.2%
SWUTC survey
What are the environmental factors that can help people walk or walk more?
Seattle
Younger AdultsN=264
Older AdultsN=86
Rank % Rank %
Good lighting at night 1 57.6 1 55.8
Closer to other interesting places to walk to 2 54.9 2 50.0
Closer to or more walking trails / paths 3 54.2 5 41.9Interesting architecture or landscape to look at 4 52.7 3 45.3
Closer to park and recreation facilities 5 45.8 4 44.2
Closer to shopping places 6 44.7 6 37.2
More trees along streets 7 38.3 8 27.9
Benches and other places to rest 8 28.4 6 37.2
Longer crosswalk signals 9 20.8 8 27.9
Seattle, WBC Survey
Assessments: Examples of objective measures of the built
environment
Audit
Geographic Information System
Other Relevant Measurement Tools• Global Positioning System• Ecological Momentary Assessment• Photography & Video Recorder• Infrared Motion Sensor (indoor)
Summary
Activity Friendly Community as a Strategy to Reduce Obesity:
Modifiable environmental factors
Land Use
Destination
Distance
Street and Transport Infrastructure
(Adopted from Lee and Moudon 2005)
Site Design
Pedestrian & Bicycle Facilities
Recreational
Facilities
Visual Quality
Architecture
Urban Design & Amenity
Safety!
Safety!
Safety!
0.6
1.5
5.3
10.0
3.3
3.2
5.4
2.6
7.8
8.7
1.4
3.1
12.1
11.6
2.1
3.9
23.0
15.7
0.1
0.01
0.8
0.6
0.1
0.1
0 5 10 15 20 25
1977-78
1994-96
1977-78
1994-96
1977-78
1994-96
1977-78
1994-96
1977-78
1994-96
Percent of Energy from Snacking
Regular Soft Drinks Fruit DrinksDiet Soft Drinks
Beer Liquor Wine
Skim ½% Whole
Low Fat Snack Foods High Snack Foods
Desserts
SweetenedBeverages
AlcoholicBeverages
Milks
SaltySnack Foods
Changes in Major Food Sources of Energy From Snacking: Young Adults Aged 19-29
23.0
Total 15.7
14.3
15.7
10.0
12.5
8.8
5.8
11.5
5.9
Zizza et al 2001 Prev Med 32:303
1.0
4.5
13.1
11.3
3.1
5.7 5.8 6.2 6.3
1.4
4.5
16.8
12.6
3.5
5.9
7.4 7.16.7
1.6
4.8
15.1
3.6
7.0 7.3
6.1
8.0
19.9
0
2
4
6
8
10
12
14
16
18
20
Salty Snacks Desserts Soft Drinks Fruit Drinks French Fries Hamburgers Cheeseburgers Pizza Mexican Food
Ou
nce
s
1977-78
1989-91
1994-98
Portion Sizes for Selected Foods for Individuals Aged 2 and Older, USA 1977-1998
Nielsen & Popkin 2003 JAMA 289:450-453.
2
1
4
2
0
2
10
2
0
13
10
3
4
9
1
6
2
0
3
1
2
4
1
10
5
2
5
9
2
8
3
0
3
1
2
4
2
7
4
2
10
0
2
4
6
8
10
12
14
Sa
lty s
na
cks
De
sse
rts
Ca
nd
y
So
ft d
rin
ks
Fru
it d
rin
ks
Alc
oh
ol
Fre
nch
frie
s
Ha
mb
urg
ers
Ch
ee
sebu
rge
rs
Piz
za
Me
xica
n
Low
& m
ed
fat
milk
me
d &
hig
h fa
tb
eef &
por
k
Hig
h fa
tlu
nch
me
ats
&h
otdo
gs
'77-78 '89-91 '94-96
Trends in Total Energy Intake: The Proportion of Energy by Food Source for US Adolescents
Aged 12-18
Nielsen et. Al. (2002). Obesity Research 10: 370-378.
Pe
rce
nta
ge
of
tota
l da
ily k
cal
Trends in Total Energy Intake by Location, 1977- 96
0
74
5 6
11
30
68
3
17
9
21
60
5
19
86
0
20
40
60
80
Ve
nd
ing
at H
om
e
Sto
re e
ate
n o
ut
Rst
rnt/f
ast
foo
d
Sch
oo
l
Oth
er
Pe
rce
nta
ge
1
71
8
14
15
1
67
3
25
03
1
53
8
31
1
6
0
20
40
60
80
Ve
nd
ing
at H
om
e
Sto
re e
ate
n o
ut
Rst
rnt/f
ast
foo
d
Sch
oo
l
Oth
er
Ages 12-18 Ages 19-29
Nielsen et. Al. (2002). Obesity Research 10: 370-378.
'77-78 '89-91 '94-96
0.8
2.8
1.11.6
8.0
0.5
1.7
0.9
7.0
2.2
3.5
5.0
0.3
2.0
0
2
4
6
8
10
Coffeeand tea
Soft drinks Fruit drinks Alcohol Milk Other milkbev
Fruit juice
1977-78 1999-01
Trends in Beverage Consumption Between 1977 and 2001(the % of total daily calorie intake from each beverage for all
Americans aged 2 and older)
Source: Source:Nielsen & Popkin 2004 Am J Prev Med 27: 205-10.*All changes significant at the 0.01 level between 1977-78 and 1999-2001
Per
cen
tag
e o
f da
ily c
alor
ie in
take
Trends in the Mean Percentage of Consumers, Mean Servings/Day, and Mean Portions of Specific Beverages
% Consumers
61.4
76.079.0
67.4
0
10
20
30
40
50
60
70
80
90
1977-78 1994-96
Calorically-Sweetened beverages Milk beverages
Servings
2.0
2.4
3.0
2.2
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
1977-78 1994-96
Portions (ounces)
13.6
21.0
11.710.9
0
5
10
15
20
25
1977-78 1994-96
Source: Source:Nielsen & Popkin 2004 Am J Prev Med 27: 205-10.
0.2
2.6
0.30.6
3.9
0.3
3.9
0.7
1.7
7.1
0.1
6.5
0.3 0.3
8.0
0.0
4.1
0.1 0.1
5.0
0
2
4
6
8
10
Vending Ate at home Store eaten out Restaurant/fastfood
Total ofbeverages
Pe
rce
nta
ge
of
tota
l da
ily c
alo
rie
s
1977-78 Total sweetened bev 1994-96 Total sweetened bev
1977-78 Total milk 1994-96 Total milk
Trends in Sweetened Beverages and Milk Consumption by Location 1977-96. (Each figure represents the % of total daily
calorie intake by location and meal type for each year)
Source: Source:Nielsen & Popkin 2004 Am J Prev Med 27: 205-10.
0
5
10
15
20
25
All ages 2-18 yr olds 19-39 yr olds 40-59 yr olds 60+ yr olds
Soft drinks Fruit drinks Milk
Fruit juice Alcohol Coffe and tea
Other milk beverages
U.S. Beverage Consumption in 1999-2001: What proportion of our calories come from each type of beverage?
Source:Nielsen & Popkin 2004 Am J Prev Med 27: 205-10.
7.0
2.2
5.0
2.0
3.5
0.90.3
6.9
3.4
8.3
2.70.30.50.3
9.8
2.5
3.8
1.6
4.8
1.00.3
5.0
1.2
3.9
1.6
4.9
1.20.3
3.0
1.2
4.6
2.4
2.6
1.10.6
Per
cen
tag
e o
f to
tal d
aily
kca
l fr
om e
ach
be
vera
ge
Level 1: Water
• Water-essential for life
• For average person with 2200 kcal per day: 16-24 ounces or more per day but this could provide all beverage needs of about 98 ounces
• Needed for adequate hydration
• Dehydration: impaired cognition, moodiness, physical work performance, increased risk of bladder, colon, breast cancer
Level 2: Tea and Coffee
• Tea and Coffee – selected benefits on chronics, no adverse health effects in terms of obesity and chronic diseases. The only issue is for high added cream and sugar such as for gourmet coffees
• Tea: animal work strong for tea’s protective role against selected cancers; unclear benefits in humans. Potential health benefits of flavonoids in tea are unclear
• Coffee: mild antidepressant, some evidence lowers risk of Type 2 diabetes
• Caffeine: 400 mg limit. 32 ounce limit coffee [150 mg caffeine limit if pregnant]
Level 3: Low Fat and Skim Milk and Soy Beverages
• Skim Milk – unclear benefits on weight gain and bone density and fractures. Range of meta-analyses and one recent 48-week trial show no benefits for weight loss. Important benefits as protein source for child linear growth. Also major provider of calcium and vitamin D
• Adult milk intake may adversely affect several chronic diseases (prostate cancer, ovarian cancer)
• Current consumption patterns indicate milk products are important contributors of many key nutrients
• High sweetness in these beverages holds the possibility that consumption of these sweet beverages may condition a preference for sweetness
• Animal work suggests that altering the ability of the sensory properties of food to predict the caloric consequences of consuming that food may impact energy regulation and body weight
Level 4: Noncalorically-Sweetened Beverages
• Fruit juices: high in energy content, contribute limited nutrients. IOM states that two-thirds of all fruit intake should be from fruit. Limit to 4-8 ounces/day
• Vegetable juices: fewer calories, significant amounts of sodium
• Whole milk: Saturated fats are not needed beyond infancy
Level 5: Caloric Beverages with Some Nutrients
Level 5: Caloric Beverages with Some Nutrients (continued)
• Sports drinks – reduced energy density over soft drinks, helpful for hydrating endurance athletes, provides small amounts of key minerals
• Alcohol – only the ethanol benefit is clear. Moderate intake (1 drink-women, 2 for men) linked with reduced mortality, CVD, type II diabetes
• Calorically-sweetened beverages are associated with increase dental cares, Type II diabetes and weight gain
• Animal and human research show a potential relationship with weight gain but the data are not conclusive yet
Level 6: Calorically-Sweetened Beverages
What is the proportion of energy from beverages a person should consume?
• Today 21% of kcal from beverages. Need to reduce this level
• Current food composition means about 81% of our water needs must come from beverages. This varies with fruit and vegetable intake patterns
• IOM and USDA present one acceptable meal pattern for person with 2200 kcal needs. Only needs 14% of kcal
from beverages. This is 2849 ml or 98 ounces
IOM Ideal Meal Layout of Beverages for Man with 2200 kcal Intake
• The size of beverage needs varies based on diet [e.g., fruit and vegetables contain water], individual needs
• Individuals can readily live with no kcal in diet from beverages
• Clearly some people can also live with very high caloric intake from beverages but the hope is to reduce considerably the average American’s % of energy from beverages to 5-15% from the current 20% and higher level
Recommendations
• Two options: the panel’s suggested beverage pattern. 10% of energy from beverages [or less]
• Acceptable Beverage pattern (14% of energy from beverages)
Average Beverage Intake Patterns for U.S. Adults Aged 19 and Older, 1999-2002
a. Fluid Ounces Consumed b. Kcal Consumed per dayTotal 114 FL OZ Total 464 KCALS
NONCALORICALLY- SWEETENED BEVERAGES (5 FL OZ)
LOW FAT MILK(3 FL OZ)
LEVEL I
LEVEL II
LEVEL III
LEVEL IV
LEVEL VI
LEVEL V
NONCALORICALLY- SWEETENEDBEVERAGES (1 KCALS)
TEA/COFFEE,UNSWEETENED(11 KCALS)
LEVEL I
LEVEL IILEVEL III
LEVEL IV
LEVEL VI
LEVEL V
WATER (0 KCALS)
WATER (46 FL OZ)
TEA/COFFEE,UNSWEETENED
(15 FL OZ)
CALORICALLY-SWEETENEDBEVERAGES
(20 FL OZ)
CALORIC BEVERAGESWITH SOME NUTRIENTS
(15 FL OZ)
CALORIC BEVERAGESWITH SOME NUTRIENTS
(213 KCALS)
CALORICALLY-SWEETENEDBEVERAGES (211 KCALS)
LOW FAT MILK (29 KCALS)
Suggested and Acceptable Beverage Consumption Patterns for a Person with a 2200 kcal Energy Requirement per Day
a. Suggested Pattern(10% of energy from beverages)
Total 98 FL OZ Total 98 FL OZ
NONCALORICALLY- SWEETENED BEVERAGES (0 FL OZ)
LEVEL I
LEVEL II
LEVEL III
LEVEL IV
LEVEL VILEVEL V
LEVEL I
LEVEL II
LEVEL IV
LEVEL III
LEVEL V
b. Acceptable Pattern(14.% of energy from beverages)
ALCOHOL (BEER)(0 FL OZ)
FRUIT JUICES(4 FL OZ)
CALORICALLY SWEETENED
WITH NUTRIENTS
CALORICALLY-SWEETENED BEVERAGES
WITHOUT NUTRIENTS(0 FL OZ)
NONCALORICALLY- SWEETENED BEVERAGES (12 FL OZ)
ALCOHOL (BEER)
(12 FL OZ)
FRUIT JUICES
(8 FL OZ)
CALORICALLY SWEETENED
WITH NUTRIENTS
CALORICALLY-SWEETENED BEVERAGES
WITHOUT NUTRIENTS(0 FL OZ)
LEVEL VI
Footnote: The Panel suggests a range for each level of beverage that is from 100% water to: Water 20-50 fl oz/d; tea and coffee (unsweetened) 0-40 fl oz/d (can replace water; caffeine is a limiting factorup to 400 mg/d or about 32 fl oz/d of coffee); low fat and skim milk and soy beverages 0-16 fl oz/d; noncalorically-sweetened beverages 0-32 fl oz/d (could substitute for tea and coffee with the same limitations regarding caffeine); caloric beverages with some nutrients: 100% fruit juices 4-8 fl oz/d, alcoholic beverages 0-1 drink per day for women and 0-2 drinks per day for men, whole milk 0 fl oz/d; calorically sweetened beverages 0-8 fl oz/d.
WATER (50 FL OZ)
TEA/COFFEE,UNSWEETENED
(28 FL OZ)
LOW FAT MILK (16 FL OZ)
LOW FAT MILK (6 OZS)
TEA/COFFEE,UNSWEETENED
(36 FL OZ)
WATER (24 FL OZ)