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Obesity and the built environment
Obesity Issues ProgramNational Press Foundation
University of Colorado at Denver
Janne Boone-Heinonen, PhD, MPHAssistant Professor of EpidemiologyOregon Health & Science University
Penny Gordon-Larsen, PhDProfessor of Nutrition
University of North Carolina at Chapel Hill
April 30, 2013Key referenceBoone-Heinonen J, Gordon-Larsen P. Am J Prev Med. 2012;42(5): e37-46.
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Session objectives
1. Conceptual framework for research on the built environment and obesity
2. Overview of the evidence: examples of studies on key built environment features• Diet• Physical activity
3. Issues to consider when evaluating built environment research
Challenges of studying how the built environment effects obesity
4. What is on the horizon?
Section 1.Conceptual framework
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What is an obesogenic environment?
What aspects of the environment support this…
…as opposed to this?
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The Built Environment
“Consists of the neighborhoods, roads, buildings, food sources, and recreational facilities in which people live, work, are educated, eat, and play”– Sallis & Glanz 2006 Future Child
Key referencesSallis JF, Glanz K. Future Child. Spring 2006;16(1):89-108.Saelens BE, Sallis JF, Frank LD. Ann Behav Med. Spring 2003;25(2):80-91.Saelens BE, Handy SL. Med Sci Sports Exerc. Jul 2008;40(7 Suppl):S550-566.ç
Also known as: “neighborhood environment”, “obesogenic environment”, “physical environment”, “physical activity environment”, “food environment”
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Obesity-related policy strategies
White House Task Force on Childhood Obesity (Let’s Move!)
Recommendation 5.13: Increase the number of safe and accessible parks and playgrounds, particularly in underserved and low-income communities.
Recommendation 4.2: Local governments should be encouraged to create incentives to attract supermarkets and grocery stores to underserved neighborhoods.
Los Angeles Ordinance #180103…prohibit the establishment of new fast food
restaurants in South Los Angeles that will be effective for 365 days…
White House Task Force on Childhood Obesity Report to the President: http://www.letsmove.gov/white-house-task-force-childhood-obesity-report-presidentLA Ordinance: http://cityplanning.lacity.org/Code_Studies/Misc/FastFoodInterim.pdf; Sturm & Cohen. Health Aff. 2009;28(6): w1088-w1097
Section 2.Overview of evidence
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SupermarketsA source of affordable, fresh produce?
ARIC Study. Census tract-defined neighborhoods. Adjusted for other types of food stores, food service plans, income, and education.
Fruits and vegetables
Total fat
Saturated fat
Cholesterol
54%
22%
30%
-6%
Blacks
Likelihood of meeting dietary guidelines among adults with 1+ supermarkets in their neighborhood, relative to no supermarkets
Morland et al. Am J Public Health. 2002;92:1761-1767
Photo: examiner.com
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Food deserts?
Food desert (USDA definition)Low income census tract where either a ‐substantial number or share of residents has low access to a supermarket or large grocery store
http://www.npr.org/blogs/thesalt/2013/03/13/174112591/how-to-find-a-food-desert-near-youMap from: USDA Food Atlas
Access to Affordable and Nutritious Food – Measuring and Understanding Food Deserts and Their Consequences: Report to Congress. Administrative Publication No. (AP-036) 160 pp, June 2009
• Few households live in food deserts
• Most low-income households shop for food outside their neighborhoods
• Transportation barriers
Food swamps?Prof. Donald Rose, Tulane University
Access to healthy and unhealthy foods may influence diet
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Food swampsEasy access to affordable, calorie dense food?
Convenience stores
Fast food restaurants
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Fast food restaurantsA source of affordable, high calorie foods?
Women’s Health Initiative. Fast food density per 1,000 persons w/in 1.5 miles of home. Adjusted for birth cohort, race/eth, education, marital status, income, urbanicity, population density, availability of grocery stores, neighborhood SESDubowitz et al. Obesity. 2012;20(4):862-71
Greater BMI in women living in areas with greater fast food restaurant density
For 5’ 4” person:BMI of 29.0 = 169 poundsBMI of 29.3 = 171 pounds
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Other retail food outlets of interest
Small grocery stores
Supercenters
Farmers marketsVegetable and produce markets
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Obesity & The EnvironmentThe University of North Carolina at Chapel Hill
Suburban development, many cul-de-sacs
Well-connected urban development with mixed land uses
Walkability/Urban sprawlSupporting walking and cycling for transportation?
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Example: walkability/urban sprawl
SMARTTRAQ. 1-km network buffers. Adjusted for gender, age, education, ethnicity.Frank et al. Am J Prev Med. 2005;25(2S2):117-125
1 (lowest walkability)
2
3
4 (highest walkability)
1.0
1.6
2.0
2.4
Graded increase in likelihood of performing 30+ minutes/day of moderate-intensity physical activity with greater walkability index
Photo: http://christophgielen.com/christoph_gielen.html
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Recreation facilitiesSettings for exercise
Diez Roux et al. Am J Public Health. 2007;97:493-499.MESA. Euclidean buffers. Adjusted for gender, age, income, race/ethnicity, study site, perceived neighborhood violence.
Greater proportion reporting physical activity 1+ times per week with greater density of recreational resources
Section 3.Challenges and knowledge gaps
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1. Why do you live where you live?
Who lives on Main Street?
Main street Walk to the store
?
Who lives in the suburbs?
Suburbs Walk to the store
?
Downtown commuteBudget constraints
Preference to walk to the store
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Do supermarkets lead to healthier diets?Another look with data that follows people over time
CARDIA Study. Supermarkets per 100,000 population. Adjusted for individual-level sociodemographics and census tract-level poverty.Boone-Heinonen, et al. Arch Int Med. 2011;171(13):1162-1170
Supermarkets
Assess changes in diet quality related to changes in supermarket availability, analyzed in two different ways:
Comparable to prior studies: expected findingsFocusing on changes over time: relationship no longer apparent
Complex decisions about where to livePurposeful placement of supermarkets
WHY?
Diet Quality
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2. Does the built environment effect everyone equally?
ARIC Study. Adjusted for other types of food stores, food service plans, income, and education.
Fruits and vegetables
Total fat
Saturated fat
Cholesterol
54%
22%
30%
-6%
8%
9%
9%
0%WhitesBlacks
Percent increase in likelihood of meeting dietary guidelines in the presence of 1+ supermarkets in the census tract of residence (versus no supermarkets)
Morland et al. Am J Public Health. 2002;92:1761-1767
Differences in associations are observed for numerous aspects of the food and physical activity environments
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3. What is a neighborhood?Consider…
How far will you walk……to the park?…for coffee?
How far will you drive……to the gym?
…to the grocery store?…for a burger?
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Neighborhood buffers
Also: ZIP codes, Census Tracts, Census Block Groups
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2 & 3. The way we should define neighborhoods may vary by gender, income, race/ethnicity, urbanicity, and others
Relationship only found in low-income men, within 2 miles of homes
*
Why not low-income women?Why not high-income men?Why only close to home?
Fast food restaurants
WHY?
CARDIA Study. Fast food restaurants per 10,000 population. Adjusted for individual-level sociodemographics and census tract-level poverty.Boone-Heinonen, et al. Arch Int Med. 2011;171(13):1162-1170
Photo: http://trimet.org
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4. What else is in your neighborhood?Teasing apart complex neighborhood environments
• Density (walkability) may be important for physical activity
• Many aspects captured by urbanicity
Alternative built environment measures:• Resources per 10,000 population• Resources per mile of road• Ratios of healthy/unhealthy resources
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5. Many diet, physical activity, and health outcomes
Fast food restaurants
Supermarkets
Physical activity settings
Section 4.What is on the horizon?
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Approaches for looking at multiple diet, physical activity, and health outcomes: complex statistical modeling
Fast food restaurants
Supermarkets
Physical activity settings
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Looking beyond the residential neighborhood
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What is a “healthy” food resource?
“Healthy” “Unhealthy”
Supermarkets Convenience stores
Sit-down restaurants Fast food restaurants
Grocery stores? Grocery stores?
Other features of interest• Specific type (Chipotle vs. Burger King)
• Non-traditional outlets• Types of foods sold (fresh produce vs. candy)• Quality of foods sold (“fresh” vs. “not-so-fresh” fresh
produce)• Affordability (“food mirage”*)
Traditional convenience store
Village Market (Portland, OR)Photo: Rebecca Koffman, The
Oregonian*Noelle Dobson, Oregon Public Health Institute
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Many steps between neighborhood availability and diet
Availability of supermarket
Locate food items
Select & purchase food
items
Prepare food items
Consume food items
Proximity
AvailabilityIn-store marketingFood placement
AffordabilityQuality
TransportationTime constraintsPreferences: cultural, dietary
Preferences
SkillsPreferencesTime constraints
Preferences
(other neighborhood food options)
Environmental factors Individual factors
Financial constraintsPreferences
Travel to supermarket
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Proximal Leverage Point Behavioral Setting
Targets
Diet Physical activity
Restaurant industry Restaurants Portion size
Food industry & supermarket
Food stores Portion size and unit packaging
Employer Workplace Cafeteria Physical activity promotion policy
School board School, workplace, neighborhood, recreation centers
Food serviceVending machines
Community use of school gym, fields
City government & food industry
Neighborhood Fast food outletsGrocery stores
City government and developers
Neighborhood Public recreation facilities
WalkabilityCity government and police
Crime and perceived safety
Policy approaches to influencingdietary Intake and physical activity
Adapted from Popkin BM, unpublished
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Does the built environment effect ________?
•(narrow) Sidewalks• Shade• Low traffic• Parks for recreation• Cul de sacs for play
• (wide) Sidewalks• Shade• Dense, diverse (short distances)• Public transportation• Limited/expensive parking
Where would you rather…
• Walk to dinner?
• Go for a jog?
Why?
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An Ecological Model of Diet, Physical Activity, & Obesity
HealthOutcomes
BehaviorsInfluences
Developed for the NHLBI Workshop: Predictors of Obesity, Weight Gain, Diet, and Physical Activity; August 2004, Bethesda MD
Ener
gy B
alan
ce
EatingDietary patterns,nutrient intake
Sedentary Behaviors
TV, computer use,driving
Physical ActivityRecreation,
transportation,occupation,
domestic
Body Weight, Fat, &
Distribution
Risk Factors,CVD,
Diabetes,Cancers,
Costs
Biological & DemographicAge, sex, race/ethnicity, SES, genes
PsychologicalBeliefs, preferences, emotions, self-efficacy, intentions,
pros, cons, behavior change skills, body image, motivation, knowledge
Social/CulturalSocial support, modeling, family factors,
social norms, cultural beliefs, acculturation
Physical EnvironmentAccess to & quality of foods, recreational facilities, cars,
sedentary entertainment; urban design, transportation infrastructure
Policies/IncentivesCost of foods, physical activities, & sedentary behaviors;
incentives for behaviors; regulation of environments
OrganizationalPractices, programs, norms, & policies in schools, worksite,
Health care settings, businesses, community orgs
