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4 Physical Activity and the Built Environment T he second panel of the workshop examined organizations and move- ments related to physical activity and the built environment. These groups are even more diverse than those discussed during the previ- ous panel on food and agriculture, with interests ranging from community development, to transportation policy, to outdoor activity, to police–youth programs, to the use of national parks to promote the public health. Yet each has the potential to contribute to obesity prevention. COMMUNITY DEVELOPMENT The Federal Reserve has a deep commitment to the economic health of low-income communities across the country, said David Erickson, direc- tor of the Center for Community Development Investments at the Federal Reserve Bank of San Francisco.1 Each of the 12 Federal Reserve banks across the country has a community development department dedicated to fostering local development and the maximum employment possible. The Federal Reserve2 also is a bank regulator in charge of enforcing anti- redlining laws, which require banks to lend back to the communities where people make deposits. “There’s a social welfare component baked into the 1 For more information on the Federal Reserve Bank of San Francisco, see http://www.frbsf. org/index.html. 2 For more information on community development and the Federal Reserve, see http://www. federalreserve.gov/communitydev/default.htm. 25

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26 ALLIANCES FOR OBESITY PREVENTION DNA of the Federal Reserve,” said Erickson. “People don’t often realize that.” Community development is an effort to empower local communi- ties to take the reins of their economic destiny. Instead of a top-down approach emanating from Washington, DC, networks of both governmen- tal and nongovernmental players are involved in neighborhood community development corporations and local advocacy groups. These networks build affordable housing, finance small businesses, and support community facilities. Since the low-income housing tax credit was enacted in 1986, for example, 3 million high-quality apartments housing about 15 million low- income families have been built nationwide. Many groups are involved in the support of these programs, including the federal government, banks, foundations, socially motivated investors, pension funds, and insurance companies. “The point I’m trying to make,” said Erickson, “is that there is a lot of money here. It is not sufficient to the needs, but when we think about alliances . . . we have an income stream that we can work with.” Recently, the Federal Reserve has been partnering with the Robert Wood Johnson Foundation to examine and improve the social determinants of health. For example, a series of conferences held across the country has brought together people interested in public health and in community development. These conferences often feature a comparison of two maps: one that shows the prevalence of a health problem such as childhood obe- sity in the local communities across a region and another that shows the prevalence of economic hardship in the same communities. Invariably, the maps are almost identical: as economic hardship increases, the prevalence of childhood obesity also increases. “You can hear a pin drop in these meet- ings at this moment,” said Erickson. “It’s obvious that we in community development and those who worry about public health are working side by side in the same communities, but we don’t know each other.” Erickson closed by briefly mentioning three programs that he believes would be valuable allies in reducing childhood obesity: the Healthy Foods Financing Initiative3 for building grocery stores in food deserts; transit- oriented development; and small business development of companies that, for instance, provide locally sourced organic food. 3 For more information on the Healthy Foods Financing Initiative, see http://www.acf.hhs. gov/programs/ocs/ocs_food.html.

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27 PHYSICAL ACTIVITY AND THE BUILT ENVIRONMENT TRANSPORTATION POLICY Recently, the American Public Health Association4 interviewed public health professionals about the transportation profession and transportation professionals about public health professionals (Finkelstein, 2011). The results were not encouraging, said James Corless, director of Transporta- tion for America,5 a coalition of more than 400 organizations working to promote a new national transportation policy that is smarter, safer, and cleaner and provides more choice. Public health experts made statements such as “transportation planners’ emphasis is on moving cars, not people,” and “it’s common for planners to say they’ll ‘improve the roadways,’ when all they’re doing is widening the road, which creates more barriers to other modes of transportation, forcing more people into cars, and creat- ing a future need to widen the road.” Meanwhile, transportation planners characterized public health advocates as “unrealistic,” “mostly benign and somewhat naïve and uneducated about ‘the way things are,’” and “heavy- handed in pushing their agenda and demanding things to be done their way.” The transportation and public health professions are at almost opposite ends of a spectrum in terms of not only what they do but also how they think, said Corless. Transportation is a field with little regulation. The federal transportation program gives money to state departments of trans- portation and lets them decide what to do with it. Transportation planners resist even applying to transportation projects useful techniques such as health impact assessment—which could potentially expedite projects or garner more funding if the results were positive—because they believe “it is simply another box to check,” Corless commented. However, the transportation profession has slowly been changing, said Corless, and change will be accelerated in the future because the profession is in a state of crisis. A lack of money is one prominent reason, but so is a lack of political support for projects the profession wants to undertake. An emphasis on safety, which is a core mission of the transportation profession, is gradually changing the way transportation planners think. Corless quoted a recent statement from the Institute of Traffic Engineers6: “Neighborhood streets need to be designed to reduce traffic speeds. . . . Rather than adapting children to traffic, the traffic environment can be adapted to accommodate children” (Jacobsen et al., 2000, p. 73). Simi- larly, by a significant margin, Americans say that safer streets should be the primary objective of increased infrastructure support: in a 2011 poll, 4 For more information on the American Public Health Association, see http://www.apha. org/. 5 For more information on Transportation for America, see http://t4america.org/. 6 For more information on the Institute of Traffic Engineers, see http://www.ite.org/.

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28 ALLIANCES FOR OBESITY PREVENTION respondents ranked “safer streets for our communities and children” well above such goals as “a faster commute to and from work” and “high- speed intercity travel” (Rockefeller Foundation, 2011). Such results create opportunities for dialogue between the transportation and public health professions. Corless discussed three components of a healthy transportation agenda. The first is measuring the benefits of decisions made by transportation plan- ners. The public health community has much to offer, Corless believes, in terms of cost-benefit analyses and quantification of performance measures. To illustrate, he asked, “What are you actually getting as an outcome of your investments?” The second element of the agenda is participating in the transportation planning process. Different land use scenarios can be ana- lyzed, and health impact assessments can be added to projects and plans. The third element is translating walking and bicycling into cost savings. A more active population can save money overall, and research that examines these savings can generate powerful advocacy messages. The important issues in the short term, Corless concluded, are safe routes to school, crash reduction, complete streets7 policies, and health agencies advocating for active transportation policies and land use plan- ning. A more long-term (which Corless defined as 5-10 years) objective is to make health an outcome in transportation. Health should be a part of transportation cost-benefit analyses, Corless said, and health professionals should work inside transportation agencies. BRINGING BACK RECESS KEEN8 is a company based in Portland, Oregon, with a philosophy of HybridLife, said KEEN brand marketing manager Linda Balfour. She explained that the philosophy connotes “creating possibilities, caring for the world around us, and getting outside and playing.” The company believes the outdoors is any place without a ceiling, and everyone should have access to the outdoors regardless of age, ethnicity, or location. When KEEN surveyed its customers about how they engage with the outdoors, a theme of the responses was that the world is moving faster, and people have less time to get outside and play. The company also found that adults were not teaching children how to play. KEEN’s response was to launch its Recess Is Back campaign,9 which was based on several observations from a poll conducted by Harris Interac- 7A complete street is a road designed and operated to be safe for all users, including drivers, bicyclists, transit vehicles and users, and pedestrians of all ages and abilities. 8 For more information on KEEN, see http://www.keenfootwear.com. 9 For more information on the Recess is Back initiative, see http://recess.keenfootwear.com.

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29 PHYSICAL ACTIVITY AND THE BUILT ENVIRONMENT tive. First, 70 percent of U.S. working adults said they had never taken a paid recess-type break outside of lunchtime. More than half said that if a daily 10-minute outdoor recess break were initiated at their workplace, it would make them healthier, happier, or more productive employees (Busi- ness Wire, 2011). The Recess Is Back initiative was based on both a top-down and a bottom-up approach, according to Balfour. It reminded people that 10 minutes a day spent outside is not something from the distant past—it can still be part of their daily lives. The initiative held events across the United States in five major cities, created tools that people could use to spread the word about recess with their friends, and created a website with suggestions to inspire recess breaks. The website suggests different ways to experience recess, from 10-minute breaks walking the dog or a yoga break at a desk to longer weekend breaks such as a camping trip. In addition to encouraging individuals, the initiative sought to enable companies to institute recess by creating an Instant Recess Toolkit.10 As part of this campaign, KEEN partnered with Toni (Antronette) Yancey, professor of health services and co-director of the Center to Eliminate Health Disparities in the University of California, Los Angeles, School of Public Health and one of the five members of the planning committee for the workshop, to create a Recess Cost-Benefit Calculator11 that would dem- onstrate to businesses the returns they would realize by instituting a daily 10-minute recess for their employees. Yancey explained the calculator in more detail. It is based on a synthe- sis of business case studies and scientific research, including randomized controlled trials and cross-sectional studies examining the cost of injuries and of people remaining inactive versus engaging in short stints of activity. With the calculator, employers enter their number of employees, the average hourly wage, the average number of hours worked per week, the industry type, and whether the 10-minute recess will be mandatory or voluntary. The toolkit produces a conservative estimate of return on investment for 10 minutes of moderate to vigorous physical activity, disaggregated into savings from reduced absenteeism; reduced presenteeism; performance enhancement; and, after 1 year, lower medical costs. The returns per dollar invested are approximately $1.50 to $2.00 and begin to accrue within as little as 3 months, Yancey said. She noted further that, based on a more thorough analysis done after the calculator was created, a more realistic estimate of returns per dollar invested may be in the $4.00 range. 10 For more information on the Instant Recess Toolkit, see http://recess.keenfootwear.com/ recess-at-work/. 11 For more information on the Recess Cost-Benefit Calculator, see http://calculator.keen footwear.com/.

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30 ALLIANCES FOR OBESITY PREVENTION WORKING WITH THE POLICE The National Association of Police Athletic/Activities Leagues, Inc. (PAL)12 is a non-school-hour youth crime prevention program that brings police and youth together in a positive environment so they can develop trust and respect for each other. The program originated in New York City in 1914 as a response to juvenile crime and became a national program in 1940. It has more than 350 chapters nationwide and in the U.S. Virgin Islands, Puerto Rico, Canada, and Nigeria. By bringing youth under the supervision and positive influence of law enforcement, the program expands awareness of the role of law enforcement officers in the local community, and reinforces responsible values and attitudes instilled in young people by their parents. “Kids, cops, and community is a winning combination,” said PAL’s executive director, Sergeant Michael Dillhyon, “because if all those things are working together it’s positive for the whole community.” PAL is based on the conviction that if young people are reached early enough, they can develop strong, positive attitudes toward the goals of maturity and good citizenship, said Dillhyon, and obesity prevention is a natural component of that mission. PAL has been developing a program to address childhood obesity and inactivity, called Strive4Fitness®.13 This program involves working with children to encourage and inspire them to look and feel their best, perform better in sports, and excel in the class- room. PAL also has a mentoring program so youth will have an exercise or fitness buddy. And local PAL chapters around the country have a variety of programs with a nutritional component, such as culinary programs in which youth work in restaurants in Pinellas County, Florida, and Howell Township, New Jersey. HEALTHY PARKS, HEALTHY PEOPLE Almost 300 million visitors a year come to America’s national parks (National Park Service, 2011), and open spaces in natural places have always played an important role in human health and well-being. The national parks provide a prime opportunity to promote public health activi- ties, said Captain Chuck Higgins, director of the Office of Public Health for the National Park Service. Higgins recently has been leading an effort to extend the role of the national parks in public health. Known as Healthy Parks, Healthy People,14 the initiative is organized around four focus areas: demonstration and pilot projects, education, research and evaluation, and alignment and synergy. 12 For more information on PAL, see http://www.nationalpal.org/. 13 For more information on Strive4Fitness, see http://www.strive4fitness.com/. 14 For more information on Healthy Parks, Healthy People, see http://www.nps.gov/ public_health/hp/hphp.htm.

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31 PHYSICAL ACTIVITY AND THE BUILT ENVIRONMENT With regard to demonstration and pilot projects, Higgins described a program at Gulf Islands National Seashore that is attracting children to participate in the Park Service’s mission in some way. “What if we could get kids out to Gulf Islands National Seashore and help us find and mark and protect sea turtle nests? That would be fun [for the kids] . . . and they [would] have just walked two miles outside.” Another example involves making the national park concessions, one of the largest food service sup- pliers in the country, a model of sound nutrition, although “we have a long way to go,” said Higgins. The second focus area is education, and the National Park Service has a large educational staff whose job is to interpret the historical, cultural, and natural meaning of the parks for visitors. The Park Service has tested some public health messaging, and the tests have gone well, according to Higgins. The third focus area is research and evaluation. The Park Service plans to develop a research agenda that will identify research gaps related to the connection between natural spaces and public health. As a way to fill those gaps, it then plans to offer the 395 national park units in the United States as a living laboratory for research. Finally, in the area of alignment and synergy, the Park Service will examine its own policies to ensure that they support the Healthy Parks, Healthy People initiative and are aligned with other federal efforts. PLACES TO PLAY The City Project15 is ultimately a civil rights law firm, said its executive director, counsel, and founder, Robert García. It is premised not on a legal problem, but on the lives of children. Considerable social science research demonstrates the importance of physical activity and access to parks. But in communities of color and low-income communities, children have relatively few places to play. By providing children with safe places for outdoor play and opportunities for physical activity, The City Project seeks equal justice, democracy, and livability for all. The organization has used five strategies in pursuing its goals. The first is organization and coalition building. Participating in the workshop serves this mission, said García. It gives organizations like The City Proj- ect an opportunity to interact with organizations like PAL. The programs promoted by both organizations help reduce obesity and also give children positive alternatives to participating in gangs, crime, violence, and drugs. The second strategy is translating research into policy, law, and sys- temic change. The City Project recently published a report comparing the density of parks with poverty at the census tract level. The report showed that in nine counties in Southern California, children of color living in 15 For more information on The City Project, see http://www.cityprojectca.org/.

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32 ALLIANCES FOR OBESITY PREVENTION poverty with no access to a car have the worst access to parks; the worst access to playing fields; the highest levels of obesity; and the greatest risk of gang and drug activity, violence, and crime (García et al., 2009). This report has influenced legislation and guidelines in California with respect to prioritizing where park funds should be spent, García observed. The third strategy involves conducting strategic media campaigns. The week before the workshop, the public television station in Los Angeles aired on a news show a 9-minute segment called “Park Poor.” The Los Angeles Times and other newspapers have given extensive coverage to The City Project’s campaigns. García noted that the organization is using social media, such as Facebook and Twitter, to disseminate its messages. The fourth strategy is policy and legal advocacy outside the courts. For example, more than half of school districts in California fail to enforce physical education requirements that call for an average of 20 minutes per day in elementary school and 40 minutes per day in middle and high school, García commented. The City Project persuaded the Los Angeles Unified School District to observe the requirement without resorting to legisla- tion. Instead, advocates argued that it is the right thing to do based on the social science evidence and on the observation that if children of color and low-income children do not receive physical education in school, they will almost certainly not engage in physical activity outside of school. The fifth strategy is seeking access to justice through the courts in the context of a broader campaign. “We call it ‘access to justice through the courts’ because foundations don’t like to fund litigation,” said García. “But access to justice through the courts is a profoundly democratic means of enforcing the rights of people of color and low-income people who other- wise don’t have access to the legislative branch or the executive branch.” The City Project’s goal-achieving strategies have met with considerable success. When the City of Los Angeles and a developer wanted to locate a commercial project in an abandoned rail yard with no environmental review and no consideration of alternatives, The City Project organized a campaign to create Rio de Los Angeles State Park. The park has led to the greening of the Los Angeles River and has become a model for the federal government’s urban waters initiative. The New York Times called the revi- talization of the Los Angeles River a best-practice example of how cities across the nation can revitalize their inner-city areas (Ouroussoff, 2009), and the park was featured in President Obama’s report America’s Great Outdoors (Salazar et al., 2011). “We are very proud that we made it into that report,” said García. “On the other hand, we are disappointed that the report does not talk about what it took to create that park—a community organizing campaign, a lawsuit, an environmental justice argument. They act as if these parks just spring up out of nowhere. They don’t.” The City Project has had many other victories. After 3 years of liti- gation, for example, Baldwin Hills will soon be the largest urban park

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33 PHYSICAL ACTIVITY AND THE BUILT ENVIRONMENT designed in the United States in more than a century. It is adjacent to an active oil field, and the county has committed to conducting periodic public health studies of the oil field’s effects (Lass, 2011). García lauded the Institute of Medicine (IOM) for bringing together such disparate groups to look for common ground. He noted that The City Project is part of the peace movement, so for it to work with the retired generals in Mission: Readiness is “an example of the lamb lying down with the lion. Although, as Woody Allen pointed out, the lamb won’t get much sleep.” DISCUSSION In response to a question about how to link transportation planners’ concern about safety to public health concerns, Corless noted that there will continue to be a strong emphasis on safety, especially in an era of shrinking resources. The challenge is to link quantitative metrics of health to this emphasis on safety. Corless also pointed out that the way streets are built is an important cause of excessive speeding. “I walk my kids every day to school right here in Capitol Hill [in Washington, DC], and I know what we could do to fix a couple of corners for probably $10,000 each.” Linking more walkable streets to both safety and health is a way to merge these concerns, he said. Robinson asked Dillhyon what gets police officers excited about par- ticipating in PAL. Dillhyon replied that the officers who participate the most are those interested in community policing who recognize the long- term benefit to the community. Officers with a background of working with children, such as school resource officers and D.A.R.E. (Drug Abuse Resistance Education) officers, tend to gravitate toward the program. Joseph Thompson, member of the IOM Standing Committee on Obe- sity Prevention and the workshop planning committee, asked all of the pan- elists which metrics they see as most important to health and how the use of such metrics would align their disparate interests. Erickson responded that an unconventional metric would be hope. Childhood obesity is worst in the poorest neighborhoods, he observed, which reminded him of a smoking ces- sation campaign in a low-income community. Although the campaign was “flawless,” it had no effect. “The message that you might get lung cancer when you are 50 didn’t resonate with kids who didn’t think they would live to be 20. That is something that touches all of these issues.” Higgins stated that Americans have come to accept a lower state of health and well-being as normal. Empowering people to believe otherwise and defining health as a state of physical, mental, and social well-being, not just the absence of disease, would establish a new way to measure health status, he suggested. García observed that the point of building an alliance is to develop

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34 ALLIANCES FOR OBESITY PREVENTION different messages for people who are interested in different things, which implies the existence of different metrics. For instance, when The City Proj- ect began to work on equal access to parks and recreation, it emphasized a child’s right to play and have fun. However, advocating for fun did not have enough traction among community organizers and government officials. Only through a focus on the health implications of not having places to play did a lack of parks become a first-order priority among these groups. Corless said transportation safety is carefully measured and compared. The problem is that the best way to reduce pedestrian fatalities is to stop people from walking. More broad-based measures are needed, whether miles traveled on foot or just general physical activity. As an example, a smart phone application could measure how much people walk or bike each day. “Let’s do a pilot test, if it’s not already being done,” he suggested, “and figure [this measure] out community by community, and then of course across age, income, and race.” In response to a question about how to encourage children to walk or bike to school, Higgins commented that the more physical activities are integrated into daily life, the better off people will be. Many interest- ing projects are under way, such as making sure that schools and parks are located close together and are used as a unit, or linking schools and parks with trails so that there is a way to walk to any school or park in a community. The one caution, warned Corless, is that a balance must be achieved between walkable schools and school choice for students’ educa- tional attainment. Finally, Kumanyika observed that all of the members of the first panel, on food and agriculture, had common objectives centered on fixing the food system. But the organizations represented by the physical activity and built environment panel had somewhat different objectives. When the goals of public health are in opposition to the usual way of doing business, what must public health do to be a good partner? Corless emphasized that the public health community has a great deal to offer the transportation community. Having more people on well- designed streets can improve safety in multiple ways, such as by reducing both pedestrian accidents and crime. Corless said that in his experience, public health officials have greater credibility than politicians or developers in marshaling public support for transportation projects. García also responded by pointing to the increasing recognition that human health does not depend on personal choice and genetics. Rather, it depends on social determinants, including transportation; land use; access to food; and economics, encompassing income and poverty. Corless sug- gested that the common theme for the members of both panels is that atten- tion to the social determinants of health can drive progress.