Obesity and the built environment

Obesity Issues Program

National Press Foundation University of Colorado at Denver

Janne Boone-Heinonen, PhD, MPH

Assistant Professor of Epidemiology Oregon Health & Science University

Penny Gordon-Larsen, PhD Professor of Nutrition University of North Carolina at Chapel Hill
Key reference Boone-Heinonen J, Gordon-Larsen P. Am J Prev Med. 2012;42(5): e37-46.

April 30, 2013

Session objectives
1. Conceptual framework for research on the built environment and obesity 2. Overview of the evidence: examples of studies on key built environment features
Diet Physical activity

3. Issues to consider when evaluating built environment research

Challenges of studying how the built environment effects obesity

4. What is on the horizon?

Page 2

Section 1. Conceptual framework

What is an obesogenic environment?

What aspects of the environment support this as opposed to this?

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The Built Environment

Consists of the neighborhoods, roads, buildings, food sources, and recreational facilities in which people live, work, are educated, eat, and play
Sallis & Glanz 2006 Future Child

Also known as: neighborhood environment, obesogenic environment, physical environment, physical activity environment, food environment
Key references Sallis JF, Glanz K. Future Child. Spring 2006;16(1):89-108. Saelens BE, Sallis JF, Frank LD. Ann Behav Med. Spring 2003;25(2):80-91. Page 5 Saelens BE, Handy SL. Med Sci Sports Exerc. Jul 2008;40(7 Suppl):S550-566.

Obesity-related policy strategies

White House Task Force on Childhood Obesity (Lets Move!) Recommendation 5.13: Increase the number of safe and accessible parks and playgrounds, particularly in underserved and low-income communities. Recommendation 4.2: Local governments should be encouraged to create incentives to attract supermarkets and grocery stores to underserved neighborhoods. Los Angeles Ordinance #180103 prohibit the establishment of new fast food restaurants in South Los Angeles that will be effective for 365 days

White House Task Force on Childhood Obesity Report to the President: http://www.letsmove.gov/white-house-task-force-childhood-obesityPage 6 report-president LA Ordinance: http://cityplanning.lacity.org/Code_Studies/Misc/FastFoodInterim.pdf; Sturm & Cohen. Health Aff. 2009;28(6): w1088-w1097

Section 2. Overview of evidence

Supermarkets A source of affordable, fresh produce?

Likelihood of meeting dietary guidelines among adults with 1+ supermarkets in their neighborhood, relative to no supermarkets
Blacks Cholesterol -6%

Saturated fat

30%

Total fat

22%

Photo: examiner.com

Fruits and vegetables

54%

ARIC Study. Census tract-defined neighborhoods. Adjusted for other types of food stores, food service plans, income, and education. Page 8 Morland et al. Am J Public Health. 2002;92:1761-1767

Food deserts?
Food desert (USDA definition)
Access to Affordable and Nutritious Food Lowincome census tract where either a Measuring and Understanding Food substantial number or share of residents has low Deserts and Their Consequences: Report access to a supermarket or large grocery store to Congress. Administrative Publication No.
(AP-036) 160 pp, June 2009

Few households live in food deserts Most low-income households shop for food outside their neighborhoods Transportation barriers

Food swamps?
http://www.npr.org/blogs/thesalt/2013/03/13/174112591/ how-to-find-a-food-desert-near-you

Prof. Donald Rose, Tulane University Access to healthy and unhealthy foods may influence diet

Map from: USDA Food Atlas

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Food swamps Easy access to affordable, calorie dense food?

Fast food restaurants

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Convenience stores

Fast food restaurants A source of affordable, high calorie foods?

Greater BMI in women living in areas with greater fast food restaurant density

For 5 4 person: BMI of 29.0 = 169 pounds BMI of 29.3 = 171 pounds
Womens Health Initiative. Fast food density per 1,000 persons w/in 1.5 miles of home. Adjusted for birth cohort, race/eth, education, Page 11 marital status, income, urbanicity, population density, availability of grocery stores, neighborhood SES Dubowitz et al. Obesity. 2012;20(4):862-71

Other retail food outlets of interest

Farmers markets Vegetable and produce markets

Small grocery stores

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Supercenters

Walkability/Urban sprawl
Supporting walking and cycling for transportation?
Suburban development, many cul-de-sacs

Well-connected urban development with mixed land uses

Obesity & The Environment The of North Carolina at Chapel Hill PageUniversity 13

Example: walkability/urban sprawl

Graded increase in likelihood of performing 30+ minutes/day of moderate-intensity physical activity with greater walkability index
4 (highest walkability)
3 2.4

2.0

2 1 (lowest walkability)
Photo: http://christophgielen.com/christoph_gielen.html
Page 14 SMARTTRAQ. 1-km network buffers. Adjusted for gender, age, education, ethnicity. Frank et al. Am J Prev Med. 2005;25(2S2):117-125

1.6

1.0

Recreation facilities
Settings for exercise
Greater proportion reporting physical activity 1+ times per week with greater density of recreational resources

Page Euclidean 15 MESA. buffers. Adjusted for gender, age, income, race/ethnicity, study site, perceived neighborhood violence. Diez Roux et al. Am J Public Health. 2007;97:493-499.

Section 3. Challenges and knowledge gaps

1. Why do you live where you live?

Who lives on Main Street? ?
Main street Preference to walk to the store

Walk to the store

Who lives in the suburbs? ?

Suburbs

Walk to the store

Downtown commute Budget constraints

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Do supermarkets lead to healthier diets? Another look with data that follows people over time

Supermarkets

Diet Quality

Assess changes in diet quality related to changes in supermarket availability, analyzed in two different ways:
Comparable to prior studies: expected findings Focusing on changes over time: relationship no longer apparent

WHY?
Complex decisions about where to live Purposeful placement of supermarkets
PageStudy. 18 Supermarkets per 100,000 population. Adjusted for individual-level sociodemographics and census tract-level poverty. CARDIA Boone-Heinonen, et al. Arch Int Med. 2011;171(13):1162-1170

2. Does the built environment effect everyone equally?

Percent increase in likelihood of meeting dietary guidelines in the presence of 1+ supermarkets in the census tract of residence (versus no supermarkets)
Cholesterol -6% Saturated fat 0% 9% 9% 8% Whites Blacks

30% 22% 54%

Total fat Fruits and vegetables

Differences in associations are observed for numerous aspects of the food and physical activity environments
ARIC Study. Adjusted for other types of food stores, food service plans, income, and education. Page 19 Morland et al. Am J Public Health. 2002;92:1761-1767

3. What is a neighborhood? Consider

How far will you walk

to the park? for coffee?

How far will you drive

to the gym? to the grocery store? for a burger?
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Neighborhood buffers

Also: ZIP codes, Census Tracts, Census Block Groups

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2 & 3. The way we should define neighborhoods may vary by gender, income, race/ethnicity, urbanicity, and others

Fast food restaurants

Relationship only found in low-income men, within 2 miles of homes

WHY?
Why not low-income women? Why not high-income men? Why only close to home?
Photo: http://trimet.org
PageStudy. 22 CARDIA

Fast food restaurants per 10,000 population. Adjusted for individual-level sociodemographics and census tract-level poverty. Boone-Heinonen, et al. Arch Int Med. 2011;171(13):1162-1170

4. What else is in your neighborhood? Teasing apart complex neighborhood environments

Density (walkability) may be important for physical activity Many aspects captured by urbanicity Alternative built environment measures: Resources per 10,000 population Resources per mile of road Ratios of healthy/unhealthy resources

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5. Many diet, physical activity, and health outcomes

Fast food restaurants

Supermarkets

Page 24 Physical activity settings

Section 4. What is on the horizon?

Approaches for looking at multiple diet, physical activity, and health outcomes: complex statistical modeling

Fast food restaurants

Supermarkets

Page 26 Physical activity settings

Looking beyond the residential neighborhood

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What is a healthy food resource?

Healthy Supermarkets Sit-down restaurants Grocery stores? Unhealthy Convenience stores Fast food restaurants Grocery stores?

Other features of interest Specific type (Chipotle vs. Burger King)

Non-traditional outlets Types of foods sold (fresh produce vs. candy) Quality of foods sold (fresh vs. not-so-fresh fresh produce) Affordability (food mirage*)
Traditional convenience store

Village Market (Portland, OR)

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*Noelle Dobson, Oregon Public Health Institute

Photo: Rebecca Koffman, The Oregonian

Many steps between neighborhood availability and diet

Availability of supermarket Travel to supermarket Locate food items Select & purchase food items Prepare food items Consume food Page 29 items Environmental factors Individual factors

Proximity

Transportation Time constraints Preferences: cultural, dietary Preferences

Availability In-store marketing Food placement

Affordability Quality

Financial constraints Preferences Skills Preferences Time constraints

(other neighborhood food options)

Preferences

Thank You!!!
Contact Janne Boone-Heinonen boonej@ohsu.edu

Policy approaches to influencing dietary Intake and physical activity

Proximal Leverage Point
Restaurant industry

Behavioral Setting Diet

Restaurants Portion size

Targets Physical activity

Food industry & supermarket

Employer School board

Food stores
Workplace School, workplace, neighborhood, recreation centers Neighborhood Neighborhood

Portion size and unit packaging

Cafeteria Food service Vending machines Fast food outlets Grocery stores Public recreation facilities Walkability Crime and perceived safety Physical activity promotion policy Community use of school gym, fields

City government & food industry City government and developers City government and police
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Adapted from Popkin BM, unpublished

Does the built environment effect ________? Where would you

(narrow) Sidewalks rather Shade Low traffic Parks for recreation Cul de sacs for play Walk to dinner?

Go for a jog?
(wide) Sidewalks Shade Why? Dense, diverse (short distances) Public transportation Limited/expensive parking

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An Ecological Model of Diet, Physical Activity, & Obesity

Influences
Biological & Demographic Age, sex, race/ethnicity, SES, genes Psychological Beliefs, preferences, emotions, self-efficacy, intentions, pros, cons, behavior change skills, body image, motivation, knowledge Social/Cultural Social support, modeling, family factors, social norms, cultural beliefs, acculturation Organizational Practices, programs, norms, & policies in schools, worksite, Health care settings, businesses, community orgs Physical Environment Access to & quality of foods, recreational facilities, cars, sedentary entertainment; urban design, transportation infrastructure Policies/Incentives Cost of foods, physical activities, & sedentary behaviors; incentives for behaviors; regulation of environments Page 33 Eating Dietary patterns, nutrient intake

Behaviors

Health Outcomes

Sedentary Behaviors TV, computer use, driving

Energy Balance

Body Weight, Fat, & Distribution

Physical Activity Recreation, transportation, occupation, domestic

Risk Factors, CVD, Diabetes, Cancers, Costs

Developed for the NHLBI Workshop: Predictors of Obesity, Weight Gain, Diet, and Physical Activity; August 2004, Bethesda MD