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Obesity and the built environment Obesity Issues Program National Press Foundation University of Colorado at Denver Janne Boone-Heinonen, PhD, MPH Assistant.

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Presentation on theme: "Obesity and the built environment Obesity Issues Program National Press Foundation University of Colorado at Denver Janne Boone-Heinonen, PhD, MPH Assistant."— Presentation transcript:

1 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 April 30, 2013 Key reference Boone-Heinonen J, Gordon-Larsen P. Am J Prev Med. 2012;42(5): e37-46.

2 Page 2 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?

3 Section 1. Conceptual framework

4 Page 4 What is an obesogenic environment? What aspects of the environment support this… …as opposed to this?

5 Page 5 The Built Environment Consists of the neighborhoods, roads, buildings, food sources, and recreational facilities in which people live, work, are educated, eat, and play –Sallis & Glanz 2006 Future Child Key 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. Saelens BE, Handy SL. Med Sci Sports Exerc. Jul 2008;40(7 Suppl):S550-566.ç Also known as: neighborhood environment, obesogenic environment, physical environment, physical activity environment, food environment

6 Page 6 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-obesity- report-presidenthttp://www.letsmove.gov/white-house-task-force-childhood-obesity- report-president LA Ordinance: http://cityplanning.lacity.org/Code_Studies/Misc/FastFoodInterim.pdf; Sturm & Cohen. Health Aff. 2009;28(6): w1088-w1097http://cityplanning.lacity.org/Code_Studies/Misc/FastFoodInterim.pdf

7 Section 2. Overview of evidence

8 Page 8 Supermarkets A source of affordable, fresh produce? ARIC Study. Census tract-defined neighborhoods. Adjusted for other types of food stores, food service plans, income, and education. Likelihood of meeting dietary guidelines among adults with 1+ supermarkets in their neighborhood, relative to no supermarkets Morland et al. Am J Public Health. 2002;92:1761-1767 Photo: examiner.com

9 Page 9 Food deserts? Food desert (USDA definition) Lowincome census tract where either a substantial number or share of residents has low access to a supermarket or large grocery store http://www.npr.org/blogs/thesalt/2013/03/13/174112591/ how-to-find-a-food-desert-near-you Map from: USDA Food Atlas Access to Affordable and Nutritious Food – Measuring and Understanding Food Deserts and Their Consequences: Report to Congress. Administrative Publication No. (AP-036) 160 pp, June 2009 Few households live in food deserts Most low-income households shop for food outside their neighborhoods Transportation barriers Food swamps? Prof. Donald Rose, Tulane University Access to healthy and unhealthy foods may influence diet

10 Page 10 Food swamps Easy access to affordable, calorie dense food? Convenience stores Fast food restaurants

11 Page 11 Fast food restaurants A source of affordable, high calorie foods? Womens Health Initiative. Fast food density per 1,000 persons w/in 1.5 miles of home. Adjusted for birth cohort, race/eth, education, marital status, income, urbanicity, population density, availability of grocery stores, neighborhood SES Dubowitz et al. Obesity. 2012;20(4):862-71 Greater BMI in women living in areas with greater fast food restaurant density For 5 4 person: BMI of 29.0 = 169 pounds BMI of 29.3 = 171 pounds

12 Page 12 Other retail food outlets of interest Small grocery stores Supercenters Farmers markets Vegetable and produce markets

13 Page 13 Obesity & The Environment The University of North Carolina at Chapel Hill Suburban development, many cul-de-sacs Well-connected urban development with mixed land uses Walkability/Urban sprawl Supporting walking and cycling for transportation?

14 Page 14 Example: walkability/urban sprawl SMARTTRAQ. 1-km network buffers. Adjusted for gender, age, education, ethnicity. Frank et al. Am J Prev Med. 2005;25(2S2):117-125 Graded increase in likelihood of performing 30+ minutes/day of moderate-intensity physical activity with greater walkability index Photo: http://christophgielen.com/christoph_gielen.html

15 Page 15 Recreation facilities Settings for exercise Diez Roux et al. Am J Public Health. 2007;97:493-499. MESA. Euclidean buffers. Adjusted for gender, age, income, race/ethnicity, study site, perceived neighborhood violence. Greater proportion reporting physical activity 1+ times per week with greater density of recreational resources

16 Section 3. Challenges and knowledge gaps

17 Page 17 1. Why do you live where you live? Who lives on Main Street? Main street Walk to the store ? Who lives in the suburbs? Suburbs Walk to the store ? Downtown commute Budget constraints Preference to walk to the store

18 Page 18 Do supermarkets lead to healthier diets? Another look with data that follows people over time CARDIA Study. Supermarkets per 100,000 population. Adjusted for individual-level sociodemographics and census tract-level poverty. Boone-Heinonen, et al. Arch Int Med. 2011;171(13):1162-1170 Supermarkets Assess changes in diet quality related to changes in supermarket availability, analyzed in two different ways: Comparable to prior studies: expected findings Focusing on changes over time: relationship no longer apparent Complex decisions about where to live Purposeful placement of supermarkets WHY? Diet Quality

19 Page 19 2. Does the built environment effect everyone equally? ARIC Study. Adjusted for other types of food stores, food service plans, income, and education. Percent increase in likelihood of meeting dietary guidelines in the presence of 1+ supermarkets in the census tract of residence (versus no supermarkets) Morland et al. Am J Public Health. 2002;92:1761-1767 Differences in associations are observed for numerous aspects of the food and physical activity environments

20 Page 20 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?

21 Page 21 Neighborhood buffers Also: ZIP codes, Census Tracts, Census Block Groups

22 Page 22 2 & 3. The way we should define neighborhoods may vary by gender, income, race/ethnicity, urbanicity, and others Relationship only found in low-income men, within 2 miles of homes * Why not low-income women? Why not high-income men? Why only close to home? Fast food restaurants WHY? CARDIA Study. Fast food restaurants per 10,000 population. Adjusted for individual-level sociodemographics and census tract-level poverty. Boone-Heinonen, et al. Arch Int Med. 2011;171(13):1162-1170 Photo: http://trimet.org

23 Page 23 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

24 Page 24 5. Many diet, physical activity, and health outcomes Fast food restaurants Supermarkets Physical activity settings

25 Section 4. What is on the horizon?

26 Page 26 Approaches for looking at multiple diet, physical activity, and health outcomes: complex statistical modeling Fast food restaurants Supermarkets Physical activity settings

27 Page 27 Looking beyond the residential neighborhood

28 Page 28 What is a healthy food resource? HealthyUnhealthy SupermarketsConvenience stores Sit-down restaurantsFast 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) Photo: Rebecca Koffman, The Oregonian *Noelle Dobson, Oregon Public Health Institute

29 Page 29 Many steps between neighborhood availability and diet Availability of supermarket Locate food items Select & purchase food items Prepare food items Consume food items Proximity Availability In-store marketing Food placement Affordability Quality Transportation Time constraints Preferences: cultural, dietary Preferences Skills Preferences Time constraints Preferences (other neighborhood food options) Environmental factorsIndividual factors Financial constraints Preferences Travel to supermarket

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

31 Page 31 Proximal Leverage Point Behavioral Setting Targets DietPhysical activity Restaurant industryRestaurantsPortion size Food industry & supermarket Food storesPortion size and unit packaging EmployerWorkplaceCafeteriaPhysical activity promotion policy School boardSchool, workplace, neighborhood, recreation centers Food service Vending machines Community use of school gym, fields City government & food industry NeighborhoodFast food outlets Grocery stores City government and developers NeighborhoodPublic recreation facilities Walkability City government and police Crime and perceived safety Policy approaches to influencing dietary Intake and physical activity Adapted from Popkin BM, unpublished

32 Page 32 Does the built environment effect ________? (narrow) Sidewalks Shade Low traffic Parks for recreation Cul de sacs for play (wide) Sidewalks Shade Dense, diverse (short distances) Public transportation Limited/expensive parking Where would you rather… Walk to dinner? Go for a jog? Why?

33 Page 33 An Ecological Model of Diet, Physical Activity, & Obesity Health Outcomes Behaviors Influences Developed for the NHLBI Workshop: Predictors of Obesity, Weight Gain, Diet, and Physical Activity; August 2004, Bethesda MD Energy Balance Eating Dietary patterns, nutrient intake Sedentary Behaviors TV, computer use, driving Physical Activity Recreation, transportation, occupation, domestic Body Weight, Fat, & Distribution Risk Factors, CVD, Diabetes, Cancers, Costs 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 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 Organizational Practices, programs, norms, & policies in schools, worksite, Health care settings, businesses, community orgs


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