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Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
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3

Examples from Communities and Cities

Bill Purcell, currently with Farmer Purcell White & Lassiter, PLLC, began by noting that during his 8 years as mayor of Nashville, the city went from spending $1 million per year on sidewalk capital investments to spending $20 million per year. In his opening remarks for the second session

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

of the workshop, he recalled that change was not simple or straightforward; recessions intervened, and developers complained about the cost of the sidewalk program. Nevertheless, he said the initiative has endured. In fact, he reported, the new mayor of Nashville, Megan Barry, has said the city should be spending $30 million per year on sidewalks and should double the number of sidewalks citywide. The city is also creating 147 miles of bikeways and 50 miles of paved greenways. “That is what this session is about—real things happening in real time that really make a difference over the long term,” said Purcell. During the session, three panelists discussed their own experiences in North Carolina, Tennessee, and Montana, respectively.

HEALTHY COMMUNITIES IN NORTH CAROLINA

Michelle Nance, planning director for the Centralina Council of Governments (CCOG), began by noting that the Charlotte region of North Carolina is among the fastest-growing in the United States. From 1990 to 2014, the city of Charlotte added 380,000 residents, bringing its population to about 800,000, and the city is projected to add an additional 400,000 residents by 2040. At the same time, the region around Charlotte, with 2.4 million people, is expected to add 1.8 million more residents by 2050. Nance added that the region also includes distinct communities with just a few hundred people. “What that means for us,” she said, is that “we have to talk in terms of the values of the particular community that we are in.”

Nance described a planning process initiated in 2012 in the Charlotte region, called “Connect Our Future,” to establish a shared vision for the region’s growth. She reported that the process involved more than 8,400 people in a values-based discussion. Local leaders led and had ownership of the process, she noted, which included the public, private, and not-for-profit sectors. “[Local] leadership was in front the whole time,” she said. “We were responding not only to their needs but to the values of the people that they represent.”

Nance explained that the resulting plan included 10 growth priorities and a preferred growth map developed from scenarios of how the region wanted to grow, which highlighted multiple centers connected by regional transit. The growth plan also included more than 75 tools that local governments could use according to their own pace and appetite for change.

Nance noted that when attention turned to implementation of the growth plan’s priorities, it became apparent that the Centers for Disease Control and Prevention’s (CDC’s) Healthy Communities Program could be the umbrella used to serve the region.1 Participating in the Healthy

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1 More information about the program is available at https://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/index.htm (accessed January 11, 2018).

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

Communities Program, she elaborated, brought together transportation and city planners, parks and recreation officials, elected officials, city and county managers, and public health professionals. She added that their discussions encompassed transportation choices, strong downtowns, jobs and the economy, and community engagement. “It was a way to set the foundation,” she said. “We knew that we were stronger together and that having people in the same room learning the language of the other sectors was important.”

Nance went on to explain that based on what was learned from participation in the Healthy Communities Program and with a Plan4Health grant (a project of the American Planning Association [APA] in partnership with the American Public Health Association [APHA], supported by the CDC), three tools from the long-range planning process—walkability audits, park access audits, and shared- and open-use policies—were chosen for implementation and applied to West Charlotte. This community faces particular challenges, she observed, including lower household incomes; lower high school graduation rates; higher unemployment rates; higher violent crime rates; and a greater prevalence of heart disease, stroke, and diabetes relative to elsewhere in Mecklenburg County, where Charlotte is located. The big issue, according to Nance, was that life expectancy was 5 years below that in the rest of the county. “I never thought that type of indicator would show up in Mecklenburg County,” she said, “but it did.”

However, Nance continued, these were in-town communities with “good bones.” They had higher street connectivity, sidewalks, and access to transit and outdoor recreation, she elaborated, but these assets were going unused. She and her team set out to understand why. They held community meetings to understand the barriers and opportunities for physical activity within the community. Nance explained that because of previous experiences with outsiders coming into the community to do research without making any improvements, neighborhood leaders had an instinct to protect their neighborhoods. “They were very sensitive to it,” she said, “so we had to be sensitive to that, too.” By keeping things simple and asking about opportunities for and barriers to physical activity, she and her team were able to “get a bird’s eye view into what is going on.”

Nance explained that walkability audits offered a way to understand the barriers to physical activity within the neighborhoods. She and her team developed a tool that could be used with community members, and, based on input from the community meetings, chose seven street segments to audit.2 “We wanted to look at areas where people really should be walking,” she said, to understand why it was not happening.

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2 The audit tool is available at http://plan4health.us/wp-content/uploads/2015/11/ToolkitNorth-Carolina-Sample-Walk-Audit-Worksheet.pdf (accessed February 5, 2018).

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

Nance reported that the results of the audits showed that even in neighborhoods with higher street connectivity and good sidewalks, there were many barriers to walking, including blocked sidewalks, street-crossing distances that were too long, and behavioral issues such as cars parked on the sidewalk. She explained that these findings were then shared with “folks who could really get something done”: the city’s land use planners, transportation officials, and public works administrators.

One lesson Nance and her team learned was that walking audits build trust. “People really like to get out and walk with you,” she elaborated, “[and] they know you’re concerned, that you’re there to help, and the biggest part is really just listening.” She emphasized that the people closest to the problems understand them best. “Don’t make the mistake of leaving them out,” she continued. She added that the experience was also empowering for residents, who “were not only part of talking about the barriers, but they were talking through what some of the solutions may be.” In the process, she observed, community leaders learned the process for change, the city officials to contact, and the terminology to which city officials would respond. Inclusive planning can strengthen communities and increase feelings of trust and connection, she asserted, which is especially important in underserved communities, adding that residents and local leaders can be empowered to be their own advocates for change.

Some of the outcomes of this process were expected, said Nance, but others were surprising. For example, she and her team were surprised to find that sidewalks leading to new transit stops were problematic. They also found that the streets were dark and considered unsafe by residents. “Whether that is perceived or real doesn’t really matter,” she noted. She and her team conducted a streetlight inventory with help from the community. According to Nance, the success of the walking audits fed into Open Streets 704, an annual event during which the streets connecting west and uptown Charlotte are closed to cars to allow pedestrians and cyclists to move freely. She observed that one outcome of the event has been showing residents that the cultural and recreational amenities downtown are “are really not as far as they thought they were, because they were able to use the open streets to get there on foot or on bike.”

Nance then turned to the second tool chosen for implementation in West Charlotte, park access audits, which, she reported, produced similarly valuable information and lessons. Park access, she explained, is more than being able to get to a park. “It’s also, once you are there, are the facilities good for people of all ages and all abilities?” she explained. Nance and her team set out to create a simple park access audit that could be used to assess physical access to a park (by car, bike, or foot), safety (including lighting and the presence of emergency phones, illicit activity, and dangerous

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

animals), and park facilities (including their condition and level of use).3 The audit also included space for residents’ notes, observations, and recommendations. “Sometimes you will find things in the notes that are really interesting,” Nance observed. For example, the audits revealed an issue with swarming insects at one park. In another instance, the audits showed that residents walked through parks instead of on the street because it was safer.

Nance also credits the audits for revealing that park access is best measured by distance from a park entrance. “There were a lot of neighborhoods that were close to the park,” she observed, “but if the entrance is on the other side it doesn’t matter.” She cautioned that access is more than compliance with the Americans with Disabilities Act; it includes proximity to the park entrance, safe routes to walk or bike to the entrance, good lighting and emergency call boxes, and a variety of in-park activities for residents of differing ages and abilities.

Nance described that the third strategy CCOG used to increase physical activity was encouraging and supporting shared- and open-use policies. These policies, she explained, allow recreational facilities owned by schools to be used by community members during nonschool hours. Shared use generally involves contracts with recreation groups that want to use a sports field, for example, while open use is when the park or playground is open to the community. “Shared and open use of school grounds, playgrounds, and fields really creates more places to be active,” Nance argued. In 2015, she added, North Carolina passed a law that reduced the liability for school boards and school board members if someone should get hurt using a school facility outside of school hours. However, she noted, communities were still tending not to use these resources as much as they could.

Nance went on to explain that to expand shared and open use in the region, CCOG convened a task force that included representatives from the public works and schools departments to consider the administrative barriers to such uses. CCOG also conducted an inventory of all of the elementary schools in the project area and shared the results with the task force. “They will be using that [information] to develop solutions as we move forward,” Nance added. She shared several key lessons learned from this process. First, begin at a local school with a supportive principal: “Don’t start at the top, at the largest school board in the state; go to a local community.” Next, she suggested that signage is important to both welcome users and establish rules for use. Fnally, she noted that private-sector funding for open use can make it more palatable to schools. “If you can get [the private sector] involved in thinking about how they can improve the

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3 The park access audit tool is available at http://plan4health.us/wp-content/uploads/2015/11/Toolkit-North-Carolina-Park-Access-Audit-Tool.pdf (accessed February 5, 2018).

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

play space, and offering resources, it really speaks volumes to the school board,” she said.

Nance asserted that these and other interventions in Charlotte and the surrounding region have created meaningful change. “It has made a difference in how our organizations approach their work and how communities have access to their city leadership,” she said. For example, she described how walk audits are now conducted around transit stops and senior centers, and walk audit trainings have been provided to local government planners, engineers, managers, and elected officials across the state. A major change she has seen is in the timing of health impact assessments for expansions of the city’s light rail system. “We are thinking about [the health impact] up front,” she noted. “That is a really big change.” In addition, the North Carolina chapter of the APA has created a statewide, multisectoral task force to look at vibrant communities, and awards have been established for healthy communities within the state. Nance urged more collaboration of this type. “We need to work together as transportation and land use planners to think about how we can move these things forward,” she said.

Nance closed by arguing that the value proposition for creating healthy communities needs to be better developed and communicated. “We need to do a good job at linking healthy communities to economic development, to place making,” she explained. She also stated that long-term change will not occur with a single strategy: “You have to use multiple strategies. You are looking at decades of policies and programs that have gotten us to this point. It’s going to take a lot to move us forward.”

REGIONAL TRANSPORTATION PLANNING IN TENNESSEE

Leslie Meehan, director of the Office of Primary Prevention in the Commissioner’s Office of the Tennessee Department of Health, began with a quotation from David Mowat of the Canadian Partnership Against Cancer that, she said, speaks to her daily charge: “Most chronic diseases and conditions are a normal response by normal people to an abnormal environment.” Obesity is influenced by multiple factors, she pointed out, which means that solutions to the problem of obesity can address multiple contributors. Her job, she explained, is to think about how to reduce the negative impacts of environments that can promote chronic diseases, including obesity. “Our charge as transportation planners,” she elaborated, “is to think about investing in our communities and our economies, our quality of life and health, and not just thinking about the mobility of vehicles.” Land use, she explained, is the product of public policies—or the lack thereof. Referring to a crowded streetscape (see Figure 3-1), she observed, “Everything from where utility poles are to how the signs are located, to

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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FIGURE 3-1 An example of a street that does not promote active transportation or healthy eating.
SOURCES: Gary Layda, photographer. In Gaston, G. F., 2016. Shaping the Healthy Community: The Nashville Plan. Nashville Civic Design Center, Vanderbilt University Press.

the uses of the land—all of those things are influenced by policy, and that policy can certainly be amended.”

As Americans started driving more, Meehan continued, the adult and childhood obesity rate increased (see Figure 3-2). She explained that this apparent correlation drove the Nashville Area Metropolitan Planning Organization (MPO) to think about the impact of transportation on health. She defined MPOs as federally designated regional transportation planning authorities found in all urban regions of the country with 50,000 or more people that work with local governments to determine regional transportation priorities and allocate resources. Except in large metropolitan areas, she added, most sidewalks and bike lanes are funded by federal rather than local dollars, and many of these funds are funneled through MPOs. She noted that MPOs can also change policy, project prioritization, and project funding: “They have the ability to set the policy, and they have the purse, they have the funding, so they are very important organizations to know.”

Meehan continued by describing the Nashville Area MPO as encompassing about 1.3 million people in seven counties, a population that is expected to double in the next few decades. As part of its policy plan-

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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FIGURE 3-2 Vehicle miles traveled and obesity rates among children and adults in the United States, 1962–2008.
SOURCES: Presented by Leslie Meehan, September 12, 2017 (data from FHWA, 2016; Fryar et al., 2016; Ogden and Carroll, 2010).

ning process, she reported, the Nashville Area MPO conducted a random-dial telephone survey of 1,100 households, in which respondents were asked how they would spend transportation funds. “What we resoundingly heard,” she said, “was that people wanted more mass transit, they wanted more walking and bicycling facilities, and they wanted to preserve existing roadways over building new roadways.” According to Meehan, the survey showed that the public valued choice, the ability to be physically active as part of their daily transportation routine, and their time: “Whether you are spending time in your car or outside of a car for a trip, transportation takes a lot of time and can take away from our quality of life.”

Meehan explained that “we took this public opinion and we turned it into public policy.” Using the results of the survey and other sources of community input, the Nashville Area MPO developed a new regional transportation plan that guided how the organization would spend about $8 billion in transportation revenue. Meehan noted that the plan included the region’s first regional vision for walking and bicycling, proposing about 1,000 miles of both walking and bicycling facilities. Census data were then used to identify areas with higher-than-average populations of low-income, minority, and senior residents, which were areas estimated to have higher-than-average rates of chronic disease. Meehan explained that investments in

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

sidewalks, bikeways, and public transportation were concentrated in these areas to provide both mobility solutions and opportunities for physical activity. The results, she reported, included a 57 percent increase in sidewalks, a 19 percent increase in bikeways, and a 36 percent increase in greenways over the seven-county region in 4 years. Complete Streets—streets that have context-appropriate transportation facilities such as sidewalks, bikeways, and transit—increased from an estimated 2 percent of funded transportation projects to nearly 77 percent of projects in just 10 years, representing billions of dollars in transportation investments.4

Meehan added that the Tennessee Department of Health has begun several new initiatives to promote health through the built environment. For example, she explained that the department recently hired seven health development coordinators, one for each of the seven regions in the state, to think about how communities grow and how access to healthy food and opportunities for physical activity are vital not only for local economies but also for the health of populations. She also described an initiative in which the department has repurposed some of its existing funding to create Access to Health and Healthy Active Built Environment grants. One such grant provided $10,000 to 89 of 95 counties to support convening, planning, programming, infrastructure development, or evaluation of the built environment. A second type of grant provides a competitive opportunity for larger amounts of funding for similar activities, with the ultimate goal of creating publicly accessible places for people to be physically active.

“One of the questions I am asked most frequently is how the worlds of transportation and health interact together,” Meehan noted. There are many ways for the two sectors to collaborate, she continued, citing data collection as one such opportunity. She gave the example of the Nashville Area MPO’s work with the CDC and public health experts to include six health-related questions in a household travel survey. She explained that the survey provided a wealth of information to transportation planners on individuals’ transportation habits and health outcomes, and was financed through transportation funds. This information, she added, allowed the Nashville Area MPO to refine its priority areas for active transportation investment. Rather than relying on proxy census data, she elaborated, the MPO was able to use information from the travel survey to prioritize households that reported lower quality of health at the household level. These households, she observed, likely have challenges in other areas, such as jobs, housing, food, and education. “What if we joined with other agencies, not just transportation and health, to prioritize the resources of many sectors for the same populations?” she asked.

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4 More information on the program is available at https://smartgrowthamerica.org/program/national-complete-streets-coalition (accessed January 12, 2018).

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

Meehan identified modeling impacts of transportation decisions as another opportunity for transportation and public health practitioners to collaborate. She explained that in Nashville, the MPO worked with the CDC to develop a model for estimating the population health impacts of increasing active transportation in the region. A moderate scenario looked at an increase of 10 minutes a day in bicycling or walking and a 23-mile reduction in driving per week. Meehan reported that in the most conservative estimate, the model predicted a 3 percent decrease in diabetes and cardiovascular disease, while some scenarios showed up to 10 percent reductions in these health outcomes. At a minimum, she noted, the monetary savings would be $116 million per year in health care costs. “This work was really helpful for us to communicate to our elected officials, who were guiding these funding decisions, that their transportation choices were having an impact on public health,” she said.

Meehan’s final suggestion for bringing transportation and public health together was to reconsider the measures of success used by both sectors. She noted that the traditional measure of how well a roadway is working is how many cars can fit and how fast they can travel. “It’s time for us to re-think those measures,” she argued, suggesting that such measures as physical activity rates, sidewalks, sales and property taxes, obesity rates, and employment could yield a much more complete picture. Such measures extend beyond transportation and health, she asserted, and point to a “health in all policies” approach. She added that Tennessee is one of just a few states that has adopted such an approach—the Tennessee Livability Collaborative—in which 12 state agencies are using existing resources to work together on several initiatives that are expected to have great collective impact statewide. As an example, she described a pilot project that is working with several economically at-risk counties across the state to gauge the collective impact of having 12 state agencies focused on the same issues at the same time. In this way, she observed, state government can influence employment, livability, quality of life, and health all at the same time.

PHYSICAL ACTIVITY IN MONTANA

Montana is a large rural state with a statewide population density of only about six people per square mile, began Cathy Costakis, who works for Montana State University–Bozeman and is a senior consultant to the Montana Department of Public Health and Human Services’ Nutrition and Physical Activity program. She explained that obesity has been increasing in the state, and research shows that rural communities such as those in Montana experience higher levels of chronic disease relative to other areas, which may be related to obesity (Befort et al., 2012). She added that these rural differences may be due to educational attainment and to economic

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

and built environment differences at the neighborhood level (Wen et al., 2017). She noted that three-quarters of adults in Montana are not reaching the recommended physical activity levels of at least 150 minutes of moderate-intensity activity and 2 days of muscle-strengthening activity each week, and 72 percent of youth are not engaging in at least 60 minutes of physical activity each day (CDC, 2015; Montana Office of Public Instruction, 2017). “We know that we are on the right track working on built environments,” she said.

Costakis continued by reporting that in 2005, the state received its initial capacity-building grant from the CDC, and it has received a series of other CDC grants since then. “This is long-term work,” she said. “It doesn’t fit neatly within a grant cycle of 3 to 5 years and then you have these great outcomes . . . you need to build relationships. Then you need to understand the policy implications and work with multisectors . . . it takes time.”

Costakis went on to report that in 2010, the state surveyed cities with populations of 1,000 or more about their local policies on active transportation. The survey revealed that 38 percent of surveyed communities had what was considered a “gold standard” sidewalk policy for new development, defined as a 5-foot sidewalk separated from the street by a boulevard planting strip (NACTO, 2017). However, Costakis noted, while 83 percent of the largest communities had such a policy, only 20 percent of the smallest communities did, and only 5 percent of all the communities had a policy for bicycles. This lack of policy, she observed, can be seen in the built environment. “There are people out there trying to walk and bicycle, but they were not included in the facility design of the community, and that is a policy issue,” she asserted. “In many rural communities,” she continued, “the only place to walk is on the rural road, and in many cases there is no shoulder. . . . And in Montana, a lot of those roads have 70-miles-per-hour speed limits. Do you really want your kids walking there?”

According to Costakis, an additional complication in Montana is that many schools are being closed and consolidated, which increases the distance between home and school for some children and in turn makes it difficult for them to walk or bike. Equity is also an issue, she observed. To illustrate this observation, she pointed to a low-income part of a town that had fewer sidewalks and trails relative to wealthier areas in the same community. As another example, she highlighted a “great crosswalk, but as you can see it’s got no sidewalk and no curb cut. What if you have a disability? Is that a connected network for you?” She described the challenges some rural areas face, such as discrepancies in walkways near bus stops (see Figure 3-3), noting “when you get out of the bus in a city you might have a really nice pathway to go on, but if you’re in a county, well, best of luck to you, and that’s just not right.”

Costakis focused on two case studies in the state. She began with the

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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FIGURE 3-3 A sidewalk near a bus stop in the city (top), compared with a bus stop in the county (bottom).
SOURCE: Presented by Cathy Costakis on September 12, 2017.

public health department in Lewis and Clark County, in which Helena is located, which received $15,000 to work on the built environment in 2008. “We provided some technical assistance and some training, and then they ran with it,” said Costakis. She described how department members engaged the community; talked with planners and public works directors; and joined the Non-Motorized Travel Advisory Council, “which they never even knew existed.” They worked with partners to get people biking and walking to work and schools. They also sought to sell the local government

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

on the benefits of Complete Streets, Costakis noted, which led to the city adopting a Complete Streets5 policy in 2010. With some additional funding in 2012, she elaborated, the department was able to hire a staff member to lead this work. They began meeting weekly with the city engineer to discuss new projects in the city, which led to new engineering standards for subdivisions, she explained. Moreover, she continued, the department provided funding for the city to conduct an assessment to identify gaps in the sidewalk network and assess sidewalk quality and accessibility. When it came time for the city to develop its next long-range transportation plan, the city hired a consultant with specific expertise to integrate walking and biking issues throughout the plan.

Costakis reported that this work led to a Plan4Health grant (a project of the APA in partnership with the APHA, supported by the CDC), under which the Greater Helena Area Active Living Wayfinding System was established. She explained that the system identified not only trails, parks, and libraries in the city but also places to access healthy foods, such as community gardens. Another grant, from the National Association of Chronic Disease Directors and the CDC, made it possible to include people with disabilities in the department’s healthy communities work. “That . . . really helped us a lot to be more inclusive in our process,” Costakis observed. She added that the department conducted focus groups with people with disabilities to better understand their needs as they navigate the community. As a result of that engagement, she explained, signs were designed with certain colors and contrasts so that people with limited vision could still read them easily. In addition, she reported, multisector teams—including representatives from the health and planning departments, an engineer, and a person with a disability—conducted walk audits, and people with disabilities were trained to lead the audits.

Smaller communities are ideally sized for walking and biking, observed Costakis, but many lack the capacity to develop the required infrastructure. She explained that to encourage policy and environmental changes that help make communities safer, more accessible, and more inviting places for people to walk, bike, and take public transportation, the state created the Building Active Communities Initiative (BACI) Action Institute. Communities applied to attend the Institute, she elaborated, sending a leadership team of at least five people from multiple sectors. “That means elected officials, public works people, downtown business people, health care people,” she said. “We have had CEOs of hospitals come to this, superintendents of schools. We tell them the kinds of sectors that we think are important, but

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5 Complete Streets are streets designed and operated to enable safe use and support mobility for all users. For more information, see https://www.transportation.gov/mission/health/complete-streets (accessed March 16, 2018).

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

we don’t dictate to them who they bring because we know they know best who the right people are.” She added that the Institute pays travel expenses for the action teams “because we know that small communities just don’t have the capacity to do this—taking five leaders out of the community for three days in a small community is just tough.” However, she noted, the Institute covers expenses for only one car, so that the team has to drive to the Institute together—a team-building experience. At the 3-day Action Institute meeting, she explained, the teams develop action plans to take back to their communities. She reported that the Institute brings in national- and state-level speakers, holds skill-building sessions, and connects teams to resources. The teams also participate in follow-up technical assistance calls, webinars, and site visits to help them fulfill their action plans, and, she added, periodically complete brief progress reports and evaluations.

Costakis then explained that to achieve a similar goal of bringing sectors together at the state level, the National Association of Chronic Disease Directors and the CDC have also supported a national Walkability Action Institute to bring together multisector state partners interested in these issues. In Montana, she reported, these partners include representatives of the state’s departments of commerce, transportation, health, fish, wildlife, and parks; Bike Walk Montana; Montana State University; and the Montana Disability and Health Program. This group, known as the Montana Walkability Collaborative, has functioned as a steering committee for the BACI Action Institute, she noted, and additional state and local BACI advisors and sponsors help support the BACI Action Institute in multiple ways. She described this as “truly a collaborative effort.” She continued by observing that the BACI Action Institute brings the resources right to the participants; about 30 members of the Walkability Collaborative and other advisors actually attend the Institute and are able to provide on-site technical assistance to the 50 participants. To illustrate, she cited the example of how having the Department of Commerce attend the Institute can make the teams aware of available funding to help in developing an active transportation plan. Since the first BACI Action Institute was held in 2013, she continued, the number of policies focused on a healthy built environment across the state—such as Complete Streets or master plans with an active transportation component—increased from 6 to 21. Moreover, she reported that larger communities participating in the BACI Action Institute have expanded beyond Complete Streets policies to develop growth policies, transportation plans, and small-area plans.

The second case study Costakis described is in Park County, which has about 16,000 residents and is just north of Yellowstone National Park. She explained that a group from the county came to the BACI Action Institute in 2015. “Their audacious goal was to map the entire county for active transportation, and they did that,” she said. She recounted how the group

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

organized an active transportation coalition that developed a plan for making the entire county a connected place for walking and biking, with small and rural communities a particular focus. She gave the example of one solution for smaller communities that are often policy averse: hold a low-cost pop-up demonstration project so the community can understand what is possible. She described one such project in which the coalition assembled a roundabout with hay bales, protected bike lanes, and temporary crosswalks at a farmers’ market to make it easier to walk or bike to the market, a demonstration that led to permanent changes at the market to improve walkability and safety. In addition, she asserted, “where we place things is incredibly important.” She described, for example, how a local team analyzed how many people lived within a 5-minute walk of a planned new food resource center when deciding where to build the center, which led the team to choose a new location that increased the number of people who could walk there from 14 to 124.

Costakis drew several lessons from this work in Montana. First, including multiple sectors and levels is important, she argued, from the state to the local level and from cities to small rural communities. All change is local, she asserted, and the community is the expert. “We are not top-down telling them what to do,” she said; “we are just giving them some good information and having them understand the best way to go.” She cited as another lesson learned that trying quicker and less costly pilot projects gets communities excited about the possibilities, adding that successes and challenges can be shared. “Many times people don’t know from across the state what others are doing. . . . Basically, we need to break down siloes,” she said. “We have limited dollars, so if we’re not working all in the same direction it’s not going to work.”

Finally, Costakis described the best tool as taking a walk with the eyes of a child, the eyes of an older adult, and the eyes of a person with a disability. “It is a very powerful thing,” she concluded.

DISCUSSION

A discussion period followed the presentations in this workshop session. Topics discussed included barriers to change, ways to foster collaboration, social engagement, and sustaining focus on the built environment.

Barriers to Change

Focusing on the barriers that limit collaboration, Nance pointed out that transportation planning in North and South Carolina is carried out separately from land use planning. In other places, councils of government also house the MPOs, which are responsible for both land use and transpor-

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

tation planning within the region. “When [the two] are done separately,” Nance argued, “it’s a huge barrier.”

Meehan cited the importance of involving health care providers who have received clinical training in prevention work. “How do you go from health care to upstream primary prevention?” he asked. “There is a role that we all can play, no matter if we are a clinician or work as a lawyer or whatever our role is.”

Costakis mentioned the fact that many rural communities are losing population and jobs. Imposing walkability standards on new development in those communities can be seen as a barrier to investment, she explained. “We have had that conversation, and it is a tough one,” she added. “But they are coming around and they are learning from each other.”

Fostering Collaboration

Turning to how to get sectors to work together, Nance mentioned the possibility of linking collaboration with the need of many professionals to earn credit hours for their professional certifications. She noted that bringing different groups of professionals together gives them an opportunity to learn that they are all “speaking the same language.” This point was echoed by Meehan. The partners in a collaboration may define success differently, she observed, and they may or may not use such words as “equity” or “social determinants.” But, she asserted, they have similar ways of prioritizing areas of need across the state. Meehan and Costakis both highlighted the importance of understanding the priorities and decision-making processes of other sectors and then identifying areas of mutual interest on which to collaborate. “That is how we build relationships and not have people thinking they’re just doing something for us,” said Costakis. For example, Meehan shared that Tennessee’s departments of transportation, parks, and community development have begun requiring health data from organizations that are applying for grants. “This is not something that we saw several years ago,” she noted.

Meehan added that specific multisectoral objectives also can foster collaboration. In response to a question about Vision Zero policies designed to reduce traffic-related fatalities to zero through built environment modifications, for example, she pointed out that implementing such policies at all levels, from state to regional to local, encourages success. “That is where we’re going to see some of our wins,” she argued, “when you have those policies at all levels of government.”

On a related issue, the panelists commented on how best to include the private sector in collaborations. Nance pointed to the importance of getting key elected officials involved in inviting representatives of the private sector to participate. “It has to be personal,” she stressed. “It can’t be an email

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

from a planner. It has to be from the top. . . . That seems to work for us.” She termed the private sector “the silver bullet that we are looking for.” The private sector may be interested in such initiatives as Complete Streets to enable their employees to arrive earlier to work, fresher, and ready to go, she elaborated. Still, she acknowledged, government has as yet not determined the best way to engage the private sector in this work, despite the importance of the issue.

Meehan mentioned that Mayor Purcell was instrumental in bringing Nashville Chamber of Commerce members to a national Chamber of Commerce event a few years ago to think about the local chamber’s involvement in health care. She noted that their participation in this event spurred studies in the region looking at access to health care, and the chamber is now actively involved in the issue as a partner. “They want to figure out how they can be a better leader and a champion in this work,” she said, “and how they can engage with companies that are moving into our region to help them be a part of the solution.”

Costakis reported that in Billings, Montana, the chamber of commerce has branded the city “Montana’s Trailhead.” As part of that effort, she explained, the chamber convened a trails committee, boasting nearly 100 members, that works to ensure that the community is connected with an urban trail system so that residents and visitors alike can enjoy what the city has to offer. “They see it as a real economic development strategy,” she said. In Charlotte, Nance added, the local chamber has shown interest in expansion of the light rail system because areas around transit stops tend to have higher property values and economic development and economic opportunity potential.

Social Engagement

In response to a comment about how a lack of social engagement can have an even greater long-term effect than obesity on health, Nance observed that open-streets events are something any community can implement. “Just block off the street,” she said. “It’s neighbors meeting neighbors. It’s not about transportation or recreation; it’s about community.” Meehan added that the arts commission in Tennessee has been a valuable partner because of its work around place making, “which absolutely contributes to healthy, thriving communities.”

Nance suggested partnerships across demographic groups as one intriguing option. Charlotte is adding 44 people per day to its population, from millennials to seniors, she explained. “If you think about it,” she said “seniors and millennials have a lot of needs that are very similar in terms of transportation, walkability, and being near different types of services.

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

It’s an opportunity for us to be thinking about those things in conjunction with our transportation.”

Sustaining Focus on the Built Environment

When asked how to bridge the gap between short-term political thinking and long-term processes, Nance acknowledged that leaders do turn over, which can create difficulties in retaining focus on a long-term issue. Yet, she argued, local government can continue to work on an issue even when membership changes. Often, she explained, former elected officials continue to hold positions of leadership in their communities, and they can be included as ex officio leaders.

Purcell observed that even if a particular leader may not be interested in an issue, other leaders can step in to deliver what people want. “If the state is not taking care of it,” he elaborated, “the local government will step up. The federal government sometimes steps into vacuums when the others aren’t there. . . . If people really want something, at the end of the day, the elected officials will do their best to deliver it.”

Former governor of Maryland Parris Glendening commented that strong leadership on signature policy issues—such as protecting the Chesapeake Bay in Maryland—can create a focus on specific issues that outlasts political turnover. In addition, he highlighted the importance of local ownership, stating, “You don’t build a light rail system under any one mayor or even governor. What has to happen is the ownership of the business community and others [has] to really be there.”

Institutional structures also can work on issues that transcend individual leaders, Meehan noted. For example, she observed, the work of the Tennessee Resilience Council is premised on the idea that communities need not only an initial response after a disaster but also the long-term ability to recover. “The mission of that council,” she explained, “is to focus on livability and quality of life and to build some of this infrastructure into communities so that, when they do have a disaster like a hurricane or tornado, they have the infrastructure built in to figure out how to bounce back.”

Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 21
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 22
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 23
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 24
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 25
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 26
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 27
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 28
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 29
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 30
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 31
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 32
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 33
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 34
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 35
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 36
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 37
Suggested Citation:"3 Examples from Communities and Cities." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
Page 38
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The built environment—the physical world made up of the homes, buildings, streets, and infrastructure within which people live, work, and play—underwent changes during the 20th and 21st centuries that contributed to a sharp decline in physical activity and affected access to healthy foods. Those developments contributed in turn to the weight gain observed among Americans in recent decades. Many believe, therefore, that policies and practices that affect the built environment could affect obesity rates in the United States and improve the health of Americans.

The National Academies of Sciences, Engineering, and Medicine convened a workshop in September 2017 to improve understanding of the roles played by the built environment in the prevention and treatment of obesity and to identify promising strategies in multiple sectors that can be scaled up to create more healthful and equitable environments. This publication summarizes the presentations and discussions from the workshop.

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