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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary 5 Physical Activity and the Built Environment The built environment affects physical activity and energy expenditure, which in turn play a role in the prevalence of overweight and obesity in a community. Environments that facilitate walking, cycling, and use of public transit (which often involves walking, stair climbing, and other physical activity) give people opportunities for more physical activity as exercise or as part of their normal routine. Conversely, environments in which walking is unsafe, public transit is not available or convenient, or stores and other businesses are located far from residential areas encourage more automobile use and less physical activity. Harriet Tregoning (Director, Office of Planning, Office of the Deputy Mayor for Planning and Economic Development, Washington, DC), Ailsa McGinty (Policy and Stakeholder Manager, UK Cross-Government Obesity Team), and Peter Ashcroft (Regional Physical Activity Lead, UK Department of Health Southwest) shared some of the ways they are working to make the built environment healthier. They noted that: Professionals and agencies with a role to play in obesity prevention extend beyond those in the areas of health and nutrition to include those in planning, economic development, transportation, public safety, and other areas. Clear, easy-to-interpret evidence on the impact of the environment on physical activity and ultimately on health is a useful way to communicate these concerns to nonhealth professionals.
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary Opportunities to integrate health considerations into other policies and programs can increase physical activity, sometimes at little or no extra public cost. A shift away from the private automobile requires new planning tools, for example, a tool other than car counts for siting new businesses. WASHINGTON, DC: “HEALTHY BY DESIGN” Tregoning emphasized how the built environment affects the public health in general and physical activity in particular (see Box 5-1). She distinguished between physical exercise (“something I make an appointment to do”) and physical activity (something incorporated into daily life), stressing that both have measurable benefits. As an example of the positive effects development can have on physical activity, Tregoning cited Atlantic Station, a mixed-use development in Atlanta built on the property of a former steel mill. People in Atlanta drive on average 33 miles a day; people who live and/or work in Atlantic Station drive on average only 8 to 10 miles a day. Tregoning spoke about how planning can help combat obesity. Among a population of about 590,000, 54 percent of adults in Washington, DC, are overweight or obese, as are 22 percent of teens, the highest percentage BOX 5-1 Impact of the Built Environment on Public Health Harriet Tregoning, Director of Washington, DC, Office of Planning, cited five impacts that illustrate how the built environment affects public health: In low-income neighborhoods, the likelihood of a person meeting daily nutritional guidelines increases by one-third if the neighborhood has a grocery store that sells healthy food. Abundant fast food establishments, corner stores, and scarce grocery stores lead to more health problems than are seen in more balanced food environments. People living in walkable, mixed-use communities are twice as likely to get the recommended 30 or more minutes per day of physical activity. One-third of Americans who use public transit to get to work meet this recommendation. People living within one-quarter mile of a park are 25 percent more likely to meet this recommendation. SOURCE: Public Health Law & Policy, http://www.phlpnet.org.
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary in the country. The problem is estimated to cost about $372 million annually. The DC Department of Health has a Childhood Health Action Plan whose goal is to reverse the trend in childhood obesity by 2010. A District Obesity Plan is also being prepared, with objectives for increasing physical activity and the intake of healthy foods. Washington, DC, already has many elements in place to encourage more physical activity, including the country’s second-largest rail and fifth-largest bus networks; low car ownership (63 percent of households) and easy bus-stop access; 39 grocery stores and more than 19 farmers’ markets; and parks, recreation facilities, and bike lanes. The city also has pioneered bike- and car-sharing programs. For planners and other city officials, the question is how to make investments in and changes to the built environment to make communities “healthy by design.” To this end, Washington has implemented a number of policies, such as: facilitating safe ways to do different types of walking, from rambling and strolling to utilitarian trips to work and errands, by installing countdown meters at intersections, creating wide side-walks, and undertaking a Great Streets Initiative that uses planning to advance livability and walkable destinations; investing in alternative modes of transport, such as by constructing bike racks and lanes; encouraging healthy corner stores and sidewalk vending through tax incentives; developing a comprehensive plan to promote community gardens, mixed-use development, and other measures; and using technology to promote health, such as through an online directory of community gardens, healthy food stores, and nutrition classes, and to enable farmers’ markets to accept Supplemental Nutrition Assistance Program (SNAP) electronic payment for fresh produce. Looking ahead, Tregoning said future options for Washington include (1) studying the potential of a fresh food financing initiative, based on a Pennsylvania program that provides incentives to businesses that locate healthy food stores in underserved neighborhoods; (2) leveraging transit improvements to increase physical activity; (3) reforming land use and zoning regulations; and (4) engaging in more branding, outreach, and education to increase healthy eating and active living among all Washington residents.
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary INCREASING PHYSICAL ACTIVITY THROUGH THE BUILT ENVIRONMENT IN ENGLAND National Context McGinty gave an overview of national efforts to increase physical activity through the built environment before turning the podium over to Ashcroft, who discussed how these national efforts can play out on the regional level: The Healthy Weight, Healthy Lives strategy (see Box 3-1 in Chapter 3) calls for the creation of environments that promote healthy weight. Using the 2012 Olympics as a spur, the recently published Be Active, Be Healthy strategy establishes a framework within which local authorities and the National Health Service can create opportunities for sport and physical activity, with the goal of getting 2 million more people active by 2012 (UK Department of Health, 2009). Healthy Towns is a challenge-fund program that is investing £30 million in nine towns during the next 3 years to encourage holistic approaches to enhancing physical activity and food choices. Projects related to the built environment include improved signage for easier walking and cycling, urban gardens, and an awards scheme to improve the food offerings in the inner-city London community near Olympic Park. An expert working group convened by the UK Department of Health is looking at sedentary behavior and gathering evidence on the most effective ways to promote activity. The group is working with the World Health Organization, which is developing activity recommendations especially for young children. Southwest England Ashcroft spoke broadly about physical activity and the built environment, but then he also talked about strategies specific to Southwest England. He suggested that policies encouraging physical activity are important, but on their own are not enough. Policies must have strong political backing and resources, as well as advocates who can convince people to change their behavior. Influencing practice is as much an art as a science. It requires, among other things, good evidence as to what works best. Policies related to the built environment—for example, where to locate new houses, how to encourage growth in a sustainable way, and how to
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary transport people to their destinations—affect people’s lifestyles, the local community, the economy, and ultimately people’s health. In this complex and interrelated environment, it is important to coordinate the efforts of national, regional, and local agencies, as well as to work across the different silos of transportation, waste services, health, and other areas. One “sales point” Ashcroft said he finds effective is evidence, published in the Journal of the American Medical Association (Blair et al., 1989), showing that people who are more physically fit have a longer life expectancy than those who are not. About 10 percent of the UK population will live in purposefully built new developments in the next 10 years or so. Building sidewalks, linking greenspaces to each other, and encouraging mixed-use development are all ways to promote physical activity. Existing settlements can pose more of a challenge since retrofitting is tricky. Efforts to integrate physical activity options into these environments such as sidewalks and greenspaces must be more opportunistic and gradual. An upcoming conference titled “Building Health: Planning and Designing for Health and Happiness,” organized in part by Ashcroft’s office, will bring together professionals to share ideas and best practices, using Freiburg, Germany, as an example. The agenda will encompass greenspaces, transport, the public realm, major development, incremental change, facilities and services, and rural communities. Ashcroft went into two of these topics—greenspaces and transport—in some detail. Evidence shows that access to greenspaces reduces obesity by a small amount but has a large effect on physical activity levels (Ellaway et al., 2005). In the United Kingdom, the voluntary sector is very involved in the management of greenspaces, especially in urban areas, and the emphasis is on making these spaces enjoyable so people will want to return to them. New development patterns are needed in which greenspaces are set aside and linked together. In terms of transport, the goal is to increase active travel as a way to contribute to healthy living. Promoting walking and cycling often requires traffic-calming measures, reallocation of road space, and improved public transport. Different agencies must be involved in changing transportation behaviors, especially for the short trips (1 to 2 miles) that account for much automobile use. The Department of Transport’s strategic goals are supportive of change. Again, sharing evidence is effective. An example is a study that shows the link between transportation choices and not only road accidents (the traditional focus of transport planners), but also cancer, heart disease and stroke, and climate change effects (Cavill and Davis, 2007). A statement by England’s Chief Medical Officer that active travel is critical to health also underscores the linkages.
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary In southwest England, strategies to inject health considerations into decisions about the built environment include adding health issues to the training of new planners; briefing obesity prevention leaders so they can better negotiate with planners; sponsoring health impact assessments as part of transport plans; seconding a health planner into the Bristol transport team; creating active-travel investment plans; challenging weak policies; and sharing evidence about what works. Finally, communication is critical. Every planning and transport professional in the region receives on a weekly basis information that summarizes complex research and essential evidence in easy-to-read formats. Showing an impact motivates people to do more, and success breeds more success. DISCUSSION In the question-and-answer session, the discussion turned to the corporate sector and health care. Jackson noted that in the United Kingdom, unlike in the United States, the National Health Service shoulders most health-related costs of obesity. The appeal to employers is framed in terms of the effects of illness and absenteeism as a drain on the corporate environment, with good examples being highlighted. Large corporations are often more responsive than small and medium-sized enterprises, as small to medium-sized enterprises lack the same capacity to bear the costs involved. Jackson also pointed to the role of the state as an employer. As a workshop participant noted, the government lags behind the best of the private-sector employers in promoting employee wellness. The government also procures large amounts of food for public institutions. Overall, the government needs to set a good example if it is to be more effective in urging the private sector to take steps to promote physical activity. Dietz said US employers have an incentive to invest in wellness because they are paying the medical costs of their employees. Many CEOs also recognize the effect of health on competitiveness. As in the United Kingdom, efforts to promote physical activity are most common among larger companies. The case must be made to small and medium-sized companies as to why obesity is a threat to their bottom line. Because employer-provided fitness centers, walking clubs, and other such programs typically engage people who are already active, “push” strategies, such as exercise breaks and parking restrictions, can increase the numbers who engage in physical activity. Ashcroft noted that in
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Perspectives from United Kingdom and United States Policy States Policy Makers on Obesity Prevention: Workshop Summary some programs he has tracked, already-active individuals were the first to engage in workplace activity programs, and less active people subsequently joined in. The discussion then turned to the subject of evaluation. Ashcroft said his office uses evidence from other countries, such as Japan and Sweden. A main measure should be changes in behavior at the individual level, looking at how many people are becoming more active and how to influence their behavior. Tregoning noted that travel behavior is measured in the United States through the Household Transportation Survey, a very laborious process conducted only once every 12 years or so. Finding a way to measure this behavior more efficiently and comprehensively would help with planning and economic development decisions. For example, as mentioned earlier, retailers use car counts to decide where to locate their stores. Cyclist, pedestrian, and public-transit counts could be used to market properties in different ways.
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