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)