Ecological Approaches to Promoting Active Living and ......• Both the design of cities and design...

Ecological Approaches to Promoting Active Living and Preventing Childhood Obesity

For Heartland Childhood Obesity Summit. Kansas City. June 2018James F. Sallis, PhD

UC San DiegoAustralian Catholic University, Melbourne

http://sallis.ucsd.edu

http://sallis.ucsd.edu/

Disclosures

• SPARK Programs of School Specialty, Inc• HKS Architects

Outline• Principles of Ecological Models• Evidence of environmental roles in active living of youth• Evidence of environmental roles in youth obesity• Environmental disparities• Combinations of interventions are needed to be effective• How can we use this evidence to be more effective in preventing

childhood obesity?

Based onSelf-report,80+ % ofAdolescentsDo not meetPA guidelines

Accelerometer-based MVPA for Adolescents. From Hallal, Lancet, 2012

The Working Hypothesis on Causes of Chronic Diseases(Vastly Simplified)

EnvironmentsPoliciesSociety

DietPhysical ActivitySedentary Time

ObesityDiabetes

Heart DiseaseCancers

SicknessDeathCosts

GenesBiology

Psychology

Practical Policy Rationale for Environment & Policy Research

• NAM/IOM, CDC, Surgeon General, AHA, WHO, National PA Plan, and many other groups recommend policy changes as essential for improving PA, diet, and obesity.

• Policy initiatives with the intent to change PA and obesity are occurring in governments, school districts, and industry.

• Evidence is needed as a basis for this work

Have land use and transport policies greatly reduced whole domains of PA?

Many EnvironmentsEncourageovereating

Food environments have obviously changed

Healthy food environments

An Ecological Model of Health Behavior

IndividualBiologicalPsychologicalSkills

Social/Cultural

Physical Environment

Policy Context

An Ecological Model of Health Behavior

IndividualBiologicalPsychologicalSkills

Social/Cultural

Physical Environment

Policy Context

Reac

h

Perm

anen

e

Ecological Model of Four Domains of Active Living

An Ecological Framework Depicting the Multiple Influences on What People Eat

Individual Factors

(personal)

Social Environment(networks)

Macro-level Environments

(sectors)

Physical Environments

(settings)

HomeWorksites School,

AfterschoolChild-careNeighborhoods &

CommunitiesRestaurants &

fast food outlets SupermarketsConvenience &

corner stores

AccessAvailabilityBarriersOpportunities

Cognitions (e.g. attitudes, preferences, knowledge, values)

Skills and behaviors LifestyleBiological (e.g. genes,

gender, age)Demographics (e.g.

income, race/ethnicity)

Outcome expectationsMotivations Self-efficacyBehavioral capability

Societal and cultural norms and values

Food and beverage industry Food marketing and media Food and agriculture policiesEconomic systems Food production &

distribution systemsGovernment & political

structures and policies Food assistance programsHealth care systems Land use and transportation

Practices Legislative,

regulatory, or policy actions

Family FriendsPeers

Role modeling Social support Social norms

Story et al., ARPH, 2007

Principles of Ecological Models• The most effective interventions operate at multiple levels

• First, change environments and policies• Then, educate and motivate people to use the opportunities

• Environmental and policy strategies are specific to behavior• Walkability mainly affects walking for transport, not leisure

• There can be multiple levels of environmental influences• Macro environments

• Design of cities; availability of parks• Availability of healthy food outlets

• Micro environments• Attributes of streetscapes and parks• Healthy food availability, price, promotion inside stores and restaurants

Shifting the FrameBehavior change is hard

30/60/90Minutes Exercise

5 A DayFood Pyramid

CommunityBarriers

IndividualResponsibility

HealthyCommunity

HealthyLifestyle

IndividualMotivation

MACRO view: Cities Can be Designed to Move People or to Move Cars

www.activelivingresearch.org

Settings of an active city

Public Health Needs to Partner

Setting for PA

• Neighborhood

• Transportation facilities (sidewalks)

• Recreation facilities

• Schools & workplaces

Expertise for Policy, Practice

• Planners

• Transport engineers & planners

• Park & rec, landscape architects

• Educators, architects

Adolescents’ Physical Activity as Related to Built Environments: TEAN Study in the US

James F. Sallis, PhD, 1 Terry L. Conway, PhD, 1 Jacqueline Kerr, PhD 1, Brian E. Saelens, PhD,2 Lawrence D. Frank, PhD,3,4 Karen Glanz, PhD, MPH,5 Donald J. Slymen, Ph.D., 1 Kelli Cain, MA,1 James C. Chapman,

MSCE, 4

1San Diego State University; 2Children’s Hospital Seattle; 3University of British Columbia; 4Urban Design 4 Health; 5 University of Pennsylvania

Sallis et al. Preventive Medicine 2018. Funded by NIH/NHLBI 2007-2011; Grant HL083454

Participants• Adolescents aged 12-16 recruited from randomly selected households in

target block groups

• Recruitment by mail & phone• 38% response rate• N=928 youth available for analyses• 49.7% were boys and 50.3% girls

Accelerometer-based MVPA Min/day in Walkability-by-Income Quadrants

52545658606264666870

Low Income High Income

58.8

61.8

65.6

68.5

MVP

A m

inut

es p

er d

ay(M

ean

*)

Low WalkHigh Walk

Walkability: F=13.74; p =.000Income: F=2.59; p =.108Walkability X Income: F=.001; p =.981

* Adjusted for gender and age

Active Transport to School†in Walkability-by-Income Quadrants

0.0

0.5

1.0

1.5

2.0

2.5

3.0


2.0

1.1

2.6 2.5

Activ

e Tr

ansp

ort t

o Sc

hool

(Mea

n of

5 d

ays*

)Low WalkHigh Walk

Walkability: F=21.2; p =.000Income: F=4.02; p =.045Walkability X Income: F=3.5; p =.062

† Includes walking, biking, and skateboarding to and from school* Adjusted for gender and age

Min/schoolday of watching TV/videos/DVDsin Walkability-by-Income Quadrants

0

20

40

60

80

100

120


MVP

A m

inut

es p

er d

ay(M

ean

*)

Low WalkHigh Walk

Walkability: p =.007Income: p =.046Walkability X Income: NS

* Adjusted for demographics, clustering

NIK: Neighborhood Impact on Kids

• Study of 6-10 year-olds & parents• Seattle King County, WA and San Diego, CA• Neighborhoods selected for high/low PA and high/low food

environments

Saelens et al. Obesity, in press. 2018

Neighborhood Impact on Kids Study Design

Physical Activity EnvironmentHigh Low

Nutrition environm

ent

High

High PAE/High NE environmenthigh walkable - good park availability/quality- healthy food environment

Low PAE/High NE environment- low walkable - poor park availability/quality- healthy food environment

Low

High PAE/Low NE environmenthigh walkable - good park availability/quality- unhealthy food environment

Low PAE/Low NE environment- low walkable - poor park availability/quality- unhealthy food environment

Frank 2012 AJPM

NIK Sample• Child - parent pairs

• n=681 at baseline • n=618 at 2-year follow-up

• 49.6% female (children)• 79.6% of parents were mothers

• Mean child age = 9.0 years• Child race/ethnicity

• 68.6% non-Hispanic White, 16.5% Hispanic, 11.4% multi-racial, 3.5% Asian, 1.8% Black

• 54.5% from block groups with below median income

Saelens 2012 AJPM

NIK Study: Child Weight Status by NeighborhoodBaseline Results

Chart1

% Overweight% Overweight% Overweight% Overweight

%Obese%Obese%Obese%Obese

Low physical activity environment, Low nutrition environment

Low physical activity environment, High nutrition environment

High physical activity environment, Low nutrition environment

High physical activity environment, High nutrition environment

0.34

0.32

0.29

0.27

0.19

0.15

0.14

0.12

Sheet1

% Overweight%Obese

Low physical activity environment, Low nutrition environment34%19%

Low physical activity environment, High nutrition environment32%15%

High physical activity environment, Low nutrition environment29%14%

High physical activity environment, High nutrition environment27%12%

NIK 2-Year Results: Child Shift to Being NOTOverweight/Obese

Saelens in press Obesity

Chart1

Low PA/Low Nutr

Low PA/High Nutr

High PA/Low Nutr

High PA/High Nutr

Column1

0.11

0.15

0.19

0.32

Sheet1

Column1

Low PA/Low Nutr11%

Low PA/High Nutr15%

High PA/Low Nutr19%

High PA/High Nutr32%

To resize chart data range, drag lower right corner of range.

NIK 2-Year Results: Child Becoming Overweight/Obese

Relative risks 1.41* 1.49* 1.49* 1.0 (ref)

Saelens in press Obesity

Chart1

Low PA/Low Nutr

Low PA/High Nutr

High PA/Low Nutr

High PA/High Nutr

Column1

0.06

0.09

0.12

0.03

Sheet1

Column1

Low PA/Low Nutr6%

Low PA/High Nutr9%

High PA/Low Nutr12%

High PA/High Nutr3%

To resize chart data range, drag lower right corner of range.

MICRO view: Design of streetscapes matters.MAPS Measure


MAPS Mini Score Children Adolescents Adults Seniors

Commercial Segments N/A

Public Parks

Transit Stops

Street Lights

Benches

Building Maintenance

Absence of Graffiti

Sidewalk

Buffer

Tree, Awning Coverage

Absence of Trip Hazards

Marked Crosswalk

Curb Cuts

Crossing Signal

GRAND SCORE

GRAND SCORE (for Active Transport)

How do MAPS-Mini scores relate to active transportation? ADJUSTED

Dose-response of MAPS-Mini total scores and active transportFrequency for4 age groups


• Both the design of cities and design of streetscapes are important for physical activity—for youth and adults

• “More is better”: Linear relations suggest that all environments can be improved

• Implications for zoning laws, transportation goals and funding, road design guidelines, measurement of active travel, parks funding

Lessons

Income Disparities in Environments

Park Quality DisparitiesEngelberg et al. BMC Public Health, 2016, 16:395.

• In the Seattle region, an unexpected pattern was found

• Potentially because targeted investments in parks within the Seattle region have realized benefits for the most disadvantaged

• Can be considered equitable differences• In the Baltimore region, findings were in the expected

direction• Both interactions showed that the greatest disparities

existed among high-minority neighborhoods, where high-income was associated with better quality parks compared to low-income

Streetscape disparitiesThornton et al. SSM-Population Health, 2016, 2, 206-216.

• Low-income and high racial/ethnic minority neighborhoods had aesthetic and social features that made them less pedestrian-friendly

• Pedestrian features varied greatly between and within (residential versus retail) cities

• Given each city’s unique pedestrian environment, local streetscape audits are necessary to determine how to best allocate resources to address disparities in pedestrian environments.

School practices and children’s physical activity during school:

Study of 100 elementary schools

Jordan A. CarlsonAnd colleagues

Preventive Medicine, 2012

Supported by The California Endowment

School practices index and MVPA during school

The 5 index practices were:having a PE teacher y/n

providing ≥ 100 minutes/week of PE y/nhaving recess supervised by non-classroom teacher y/n

providing ≥ 20 minutes/period of recess y/nhaving ≥ 75 students/supervisor in recess y/n

21.5 22.325.5

30.1

41.1

0

10

20

30

40

50

60

70

-1 0 1 2 3 4 5 6

Min

utes

/day

of M

VPA

dur

ing

scho

ol

Number of physical activity-supportive practices (0-5)

Raw M (SD) MVPA min/day Linear (regression line)

B = 5.6 min/day/practice

p

Am J Health Promotion 2014

• Review of 43 studies of obesity prevention, diet, & PA interventions in early care & education settings, published 2010-2015. Ages 3-5 years.

• Strength of obesity prevention quantified• Each intervention strategy was coded for

• Intensity (low=educational; high=policy, environment)• Frequency of use (low=once; high=daily)

• Duration of entire intervention (low=9 months)• Scores computed for diet, PA, parent components. Plus overall intervention

score• Supported by Healthy Eating Research

• Results• Intervention strength scores for diet, PA, and combined interventions were

correlated r>.30 with at least 1 anthropometric outcome• Strength of parent engagement added to effectiveness of each intervention

category

• More indirect evidence for multi-level, multi-component interventions, emphasizing environment and policy strategies

• 130 communities studied, oversampling hi-risk communities• Community programs and policies quantified• N=5138 children 4-15 years

Healthy Community Study Results Frongillo et al. AJPM 2018• Results

• More diet and PA behaviors targeted (in past 3 years)• Lower BMI (0.8 BMI units)• Lower waist circumference (1.8 cm)

• Higher intervention intensity scores were not significantly related to outcomes

• Effectiveness depends on implementation• Environment and policy changes take longer to implement

Info for Researchers & Decision-MakersAt www.activelivingresearch.org

THANK YOU(now please stand up)

Please Become An Active City Advocate in Your Community

• This report is a useful resource• Download at http://www.designedtomove.org/resources

Physical Health

Mental Health

Social Benefits

Environmental Sustainability

Safety / Injury

Prevention

Economic Benefits

Open spaces / Parks/ Trails

57.5+3.5(0)

93+ 42.5+4(0)

20+4(0)

23+ 19+4(0)

Urban Design

105+54(0)19-

31+4-

80.5+29(0)

265.5+45.5(0)3.5-

13.5(0)18.5-

69+10.5(0)4-

Transport Systems

7+3.5-

3+3.5(0)

23+ 70+21(0)3-

67+14(0)4-

56+3.5(0)4-

Schools 19.5+3.5(0)

21+ 11+ 21.5+ 4+3-

15+

Workplaces / Buildings

55+3.5(0)

18.5+4-

20.5+ 48+3.5(0)

Co-Benefits of Designing Activity-Friendly Environments

Active Transportation by Youth has DecreasedMode for Trips to School – National Personal Transportation Survey

McDonald NC. Am J Prev Med 2007;32:509.

Examples of Creating Active Environments

% of SRTS Projects, By Type

0 10 20 30 40

Sidewalk

Crosswalk

Signage

ADA improvement

Bicycle rack

Traffic calming

Shared use path

Bicycle lane

Ped bridge

% of projects

% of projects

Moving Forward: WASH DOT. http://www.wsdot.wa.gov/research/reports/fullreports/743.3.pdf

Walking & Cycling to School Pre & Post SRTS Projects in 5 States

0

2

4

6

8

10

12

14

16

% Walking % Bicycling

Pre-projectPost-project

Moving Forward: WASH DOT. http://www.wsdot.wa.gov/research/reports/fullreports/743.3.pdf.

Ecological Approaches to Promoting Active Living and Preventing Childhood ObesityDisclosuresOutlineSlide Number 4Accelerometer-based MVPA for Adolescents. From Hallal, Lancet, 2012The Working Hypothesis on Causes of Chronic Diseases�(Vastly Simplified)The Working Hypothesis on Causes of Chronic Diseases�(Vastly Simplified)Practical Policy Rationale for Environment & Policy ResearchHave land use and transport policies greatly reduced whole domains of PA?Slide Number 10Food environments have obviously changedSlide Number 12Slide Number 13An Ecological Model of Health Behavior An Ecological Model of Health Behavior Slide Number 16Slide Number 17An Ecological Framework Depicting the Multiple Influences on What People EatPrinciples of Ecological ModelsShifting the FrameMACRO view: Cities Can be Designed to Move People or to Move CarsSettings of an active cityPublic Health Needs to PartnerAdolescents’ Physical Activity as Related to �Built Environments: TEAN Study in the US�Slide Number 25Accelerometer-based MVPA Min/day �in Walkability-by-Income QuadrantsActive Transport to School† �in Walkability-by-Income QuadrantsMin/schoolday of watching TV/videos/DVDs�in Walkability-by-Income QuadrantsNIK: Neighborhood Impact on KidsNeighborhood Impact on Kids Study DesignNIK SampleNIK Study: Child Weight Status by Neighborhood�Baseline ResultsNIK 2-Year Results: Child Shift to Being NOT Overweight/ObeseNIK 2-Year Results: Child Becoming Overweight/ObeseMICRO view: Design of streetscapes matters.�MAPS MeasureSlide Number 36Slide Number 37LessonsIncome Disparities in EnvironmentsPark Quality Disparities�Engelberg et al. BMC Public Health, 2016, 16:395.Streetscape disparities�Thornton et al. SSM-Population Health, 2016, 2, 206-216.School practices and children’s physical activity during school:�Study of 100 elementary schools School practices index and MVPA during schoolSlide Number 44Slide Number 45Slide Number 46Slide Number 47Healthy Community Study Results �Frongillo et al. AJPM 2018Slide Number 49Slide Number 50Slide Number 51THANK YOU�(now please stand up)Please Become An Active City Advocate in Your CommunityCo-Benefits of Designing Activity-Friendly EnvironmentsActive Transportation by Youth has Decreased�Mode for Trips to School – National Personal Transportation SurveySlide Number 56% of SRTS Projects, By Type�Walking & Cycling to School Pre & Post SRTS Projects in 5 States

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