Presentation on theme: "Current Efforts Related to Public Health and The Built Environment FHWA Efforts, Complexity, and Overwhelming Stressor Hypothesis David Belluck, Ph.D."— Presentation transcript:
Current Efforts Related to Public Health and The Built Environment FHWA Efforts, Complexity, and Overwhelming Stressor Hypothesis David Belluck, Ph.D. FHWA Washington, D.C.
FHWA Efforts on the Built Environment and Public Health FHWA is expending considerable resources in the field of infrastructure and public health. Three of these efforts will be described today.
FHWA's Transportation Planning & Physical Activity Project. FHWAs upcoming publication What Works: Transportation and Public Health. FHWA is working with CDC to assess whether transportation facilities can be evaluated for health impacts. FHWA Efforts on the Built Environment and Public Health
FHWA Transportation Planning & Physical Activity Project Initiative to help transportation planners and USDOT understand potential links between transportation planning and physical activity.
FHWA Transportation Planning & Physical Activity Project Main activities to Date: Meetings with public health stakeholders Annotated Bibliography - Released in 2004 Experts Peer Roundtable - January 2004 Roundtable Proceedings - Released in 2004
FHWA Portland Roundtable Transportation and public health professionals discussed opportunities and strategies to include health and activity goals within the transportation planning process. Lesson learned from this multidisciplinary effort will be used in producing What Works: Transportation and Public Health. Photo: http://lists.village.virginia.edu/sixties/Graphics/Cover s/cover_Lessons.JPEG
First Steps at Multidisciplinary Approach What Works: Transportation & Public Health is an important first step to bring together health professionals and transportation professionals to work on the problem of active transport, active living, and public health.
What Works: Transportation & Public Health Sherry Ways (FHWA) and I will shortly put together a final Statement of Work to hire a contractor to work with FHWA, along with public and private sector partners, to develop consensus themes and select consensus photographs to show how transportation may contribute to improved public health to work for the public good. It will initially be an Internet document with the potential for hard copy publication. Here is an example of how the publication could look:
Complexity The subject of obesity causation and control is very complex. There are many potential causes. Scientists and physicians are having a very difficult time getting a firm hold on all the pieces to the puzzle and figuring out how they relate to one another. Currently no unifying theory about why obesity control interventions have not met expectations (i.e. obesity still increasing). The importance of transportation infrastructure as a cause of obesity is unclear as demonstrated by the next slides.
Purported Causes of Obesity Carbohydrate intake increase Chemical toxins Childrens purchasing power Culture Early dieting in response to media induced body images Eating less meals at home Environment
Purported Causes of Obesity Genetics High birth weight Increase in sedentary behaviors Limited freedom to walk Lipostatic system set-point set at inappropriate level Lowered food costs Media messages
Purported Causes of Obesity Obesogenic food environment Parental eating behaviors and weight status Parental feeding behavior Parental smoking Physical activity reduction Pregnancy Prenatal over-nutrition Prepared foods Productivity Sleep duration, short
Purported Causes of Obesity Socioeconomic status (a complex multidimensional construct) Sugar sweetened beverages Technological change Technological innovation Television viewing increases Walking and biking less to school Western lifestyle adoption
Purported Causes of Obesity Given the number and complexity of obesity causation factors, it is difficult to point to any one of these factors alone, or in combination, and definitively rank them in order of importance. In fact, no such scientifically validated list currently exists.
What is the Role of Transportation and the Built Environment in Obesity Causation? Recent papers have focused on the relationship of sprawl on obesity. These papers have linked sprawl to lessened physical activity. They have hypothesized that transportation and the built environment are a primary cause of inactivity.
What is the Role of Transportation and the Built Environment in Obesity Causation? The implication of this and other sprawl studies is that a lack of sprawl translates into more active living (e.g. walking), less obesity and lower weights, and better general health. Graphic: http://www.mp3.com.au/img/artist/Implication%209_ RESIZED.jpg
What is the Role of Transportation and the Built Environment in Obesity Causation? New York City has over nine million residents and ranks as the city with the least amount of sprawl in the 83 metropolitan areas studied by Smart Growth America. New York City has a high residential density factor, mix of homes, jobs and services, strong town centers and downtowns, and accessible street networks. Photo: http://en.wikipedia.org/wiki/New_York_City
What is the Role of Transportation and the Built Environment in Obesity Causation? New York City boroughs had the lowest sprawl statistics in the nation (Ewing and McCann September 2003). Question: Does A Lack of Sprawl In New York City Translate Into A Model of Obesity Control? Photo: http://www.tourbec.info/voyage/popup_image.php?pI D=117&image=0
Is NYC A Good Built Environment Model for Obesity Control? Public health data from NYC suggests that a relative lack of sprawl does not mean that NYC may not be an appropriate model of obesity control through infrastructure. Graphic: http://www.richardsilverstein.com/tikun_ola m/obesity.jpg
Is NYC A Good Built Environment Model for Obesity Control? In 1996 prevalence of severe overweight in second and fifth grade school children was higher in NYC compared to the rest of the state. Numerous NYC studies highlight obesity problem in children and adults.
Is NYC A Good Built Environment Model for Obesity Control? According to Wilson (August 2003) …almost half (43 percent) of the children in New York City's public elementary schools are overweight to some extent, and a quarter qualify as obese. Hispanic children had nearly double the obesity rates of white and Asian children (31 percent versus 16 and 14 percent, respectively). African-American children fell in the middle, with a 23 percent obesity rate.
Is NYC A Good Built Environment Model for Obesity Control? The New York City Department of Health and Mental Hygiene (2003, July 2003) reports that between 1991 and 2001 obesity levels doubled in the United States with New York City adults being slightly less than the national average.
Conclusions In contrast to the implications of some sprawl studies, NYC may not be a good model for built environment and obesity control based on actual obesity statistics in the literature. Additional built environment and obesity research is required before firm relationships can be established sufficient to support large scale infrastructure interventions. Graphic: http://www.ci.nyc.ny.us/html/doh/html/survey/surve y.html
What Could Be the Underlying Reasons for Obesity Increases? We have seen that there are numerous competing hypothesis to explain the continuing obesity epidemic. I would like to provide you with a working hypothesis that might make sense to explain what we are seeing in the field and technical literature. Graphic: http://www.cis.gsu.edu/~dstraub/Research/ACIT- APIT/question.gif
Overwhelming Stressor Hypothesis I am currently working on a paper to initiate discussion on the Overwhelming Stressor Hypothesis. This paper does not currently represent FHWA policy. This paper is designed to investigate the many reasons for obesity and to try and figure out why it keeps increasing in the United States.
Logic Of Obesity Causation: A Hypothesis People are exposed to numerous controllable (escapable) and uncontrollable stressors (inescapable). Coping with multiple stressors results in chronic stress and fatigue. Chronic stress and fatigue result in consumption of readily available and inexpensive energy rich foods. Graphic: http://www.marxists.org/reference/archive/hegel/tria ds/logic.gif
Logic Of Obesity Causation: A Hypothesis Over time, people gain weight, become overweight and obese. People coping with overwhelming stressors hear public health messages to exercise more and eat a balanced diet and nutritious foods. They just cannot act on these messages because they are drowned out by more pressing concerns.
Overwhelming Stressor Hypothesis My working hypothesis is that the current prevention intervention model (education and motivation) has not worked because it targets a symptom (i.e. individual weight control) and not the core problem, overwhelming stressors. If this hypotheses is correct, then a complex systems approach is needed to replace the individual centered approach currently in use.
Evidence: Controllable and Uncontrollable Stress People are exposed to numerous controllable (escapable) and uncontrollable (inescapable) stressors (e.g. work, time, economic, social, family, etc.) (Anisman and Merali 1999) Photo: www.secondhand- mobilephones.co.uk/images/work_stress.jpg
Evidence: Controllable and Uncontrollable Stress U.S. Department of Defense study shows that high levels of stress occur at work and home. Figure: www.defenselink.mil/news/Mar2004/040308- D-6570C-012.jpg
Evidence: Men and Women Often Deal With Stress in Different Ways U.S. Department of Defense study shows that men and women are stressed in different ways. Figure: www.defenselink.mil/news/Mar2004/040308- D-6570C-012.jpg
Evidence: Controllable and Uncontrollable Stress Workplace stress results from an awareness of not being able to cope with the demands of their work environment with associated negative emotional response. (www.acc.co.nz/injury-prevention/safe-at- work/worksafe/action/hazard- management/people/stress/) www.acc.co.nz/injury-prevention/safe-at- work/worksafe/action/hazard- management/people/stress/www.acc.co.nz/injury-prevention/safe-at- work/worksafe/action/hazard- management/people/stress/ Figure: www.defenselink.mil/news/Mar2004/040308- D-6570C-014.jpg
Evidence: Longer Working Hours According to a study by the National Sleep Foundation, the average employed American works a 46- hour work week; 38% of the respondents in their study worked more than 50 hours per week. (www.libraryspot.com/know/workweek.htm) www.libraryspot.com/know/workweek.htm Figure: www.jr.co.il/humorpic/jr-wweek.jpg
Evidence: Longer Working Hours Workers in the United States put in the longest hours (among industrialized nations) on the job, nearly 2000 hours per capita in 1997, and in the period from 1980, the annual working hours in the US has been steadily rising. (www.twnside.org.sg/title/steady-cn.htm) www.twnside.org.sg/title/steady-cn.htm
Evidence: Longer Working Hours The long working hours of workers in the US (rising trend) and Japan (declining trend) is in sharp contrast with those of European workers, who are progressively working fewer hours on the job. (www.twnside.org.sg/title/steady-cn.htm) www.twnside.org.sg/title/steady-cn.htm
Evidence: Stress Leads to Fatigue Fatigue is one of the common outcomes of stress and can have a serious impact on health. (www.acc.co.nz/injury- prevention/safe-at- work/worksafe/action/hazard- management/people/stress/) www.acc.co.nz/injury- prevention/safe-at- work/worksafe/action/hazard- management/people/stress/www.acc.co.nz/injury- prevention/safe-at- work/worksafe/action/hazard- management/people/stress/ Figure: www.1001cartes.com/perso/images_perso/fatigue.jpg www.1001cartes.com/perso/images_perso/fatigue.jpg
Evidence: Stressors That Influence Weight Gain Urban and suburban designs that discourage walking and other physical activities. (Hill and Peters 1998) Figure: http://tigger.uic.edu/depts/ahaa/imagebase/maclean/ aerials1/85.JPEG
Evidence: Stressors That Influence Weight Gain Reduced access and affordability in some communities to fruits, vegetables, and other nutritious foods. (Hill and Peters 1998) Decreased opportunities for physical activity at school and after school, and reduced walking or biking to and from school. (Hill and Peters 1998) Figure: www.neon-signs.com/neon-shop/food-and- beverages-signs.htm
Evidence: Stressors That Influence Weight Gain Competition for leisure time that was once spent playing outdoors with sedentary screen time-including watching television or playing computer and video games. (Hill and Peters 1998) Figure: http://uk.oneworld.net/penguin/pollution/couch_potat o.gif
Evidence: Stressors That Influence Weight Gain An environment that promotes excessive food intake (food availability and portion size, high-fat diets, passive overeating, limited access to low fat/energy density foods), and discourages physical activity (transportation, technology, no mandatory physical education in schools, environments not conducive to physical activity). (Hill and Peters 1998) Figure: www.edgeworks.us/illustrations/images/473- Couch-Potato-Female.jpg
Evidence: Coping Results in Chronic Stress and Fatigue Coping with multiple stressors results in chronic stress and fatigue. Stress is our reaction to events, environmental or internal, that tax or exceed our adaptive resources. (www.texmed.org/cme/phn/psb/stress.asp) www.texmed.org/cme/phn/psb/stress.asp Figure: www.extension.umn.edu/distribution/familydevelopment/Im ages/DE2465-logo.gif
Evidence: Coping Results in Chronic Stress and Fatigue Stress is an internal process that occurs when a person is faced with a demand that is perceived to exceed the resources available to effectively respond to it, and where failure to effectively deal with the demand has important and undesirable consequences. (www.texmed.org/cme/phn/psb/stress.asp) www.texmed.org/cme/phn/psb/stress.asp Figure: www.texmed.org/images/stressors.gif
Evidence: Coping Results in Chronic Stress and Fatigue The Stress Process 1. Stress leads to emotional response. 2. Person selects a coping response. 3. If effective, relaxation of arousal. 4. If ineffective, arousal increases, resulting in strain. 5. Unresolved stress leads to burnout. (www.texmed.org/cme/phn/psb/what_is_stress.asp) www.texmed.org/cme/phn/psb/what_is_stress.asp Figure: www.jwolfe.clara.net/Humour/WorkStress.htm
Evidence: Stress and Fatigue Result in Consumption of Energy Rich Foods Families often minimize food costs and acquisition and preparation time, resulting in frequent consumption of energy dense convenience foods that are high in calories and fat. (National Academy of Sciences 2005) Figure: www.aperfectworld.org/clipart/food_dining/pizza.gif
Evidence: Weight Gain Over Time Over time, people gain weight, become overweight and obese. In 1991 four States had obesity prevalence rates of 15-19 percent and no States above 20 percent. In 2003 (see figure to the left) 31 States had rates of 20-24 percent, and four States had rates more than 25 percent. Figure and last two bullets: www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/obes ity_trends_2003.pdf
Lots of Health Messages Examples of messages: 1) Active play: encourage your child to get moving every day; 2) Memorable mealtimes: take time to eat together and talk with your family; 3) Television viewing: limit television viewing to one hour per day; Figure: www.infonet.st- johns.nf.ca/providers/nhhp/newsletter/spri ng00/10_Tom.gif
Lots of Health Messages 4) Drink more water: serve water at snacks; 5) Eat more fruits and vegetables: offer your child 5 fruits and vegetables each day; and 6) Active families: play with your kids. (http://nature.berkeley.edu/cwh/activities/fitwic%20VA.sht ml) http://nature.berkeley.edu/cwh/activities/fitwic%20VA.sht mlhttp://nature.berkeley.edu/cwh/activities/fitwic%20VA.sht ml Questionable effect on obesity increases over time. Figure: www2.wgbh.org/mbcweis/ltc/leadpois/CARROTS.GI F
Hierarchy of Needs People hear these messages, but may not be able to act on them because they are drowned out by more pressing concerns. If you are struggling to meet basic security needs at the bottom of the pyramid, you will not be able to focus on self actualization near the top of the pyramid that includes taking care of your health through better nutrition, exercise, rest and health care. Figure: www.deepermind.com/maslow3.png
Basic Needs Only when more basic needs are met can a person move on to higher level behaviors that would result in weight control or weight loss. Figure: www.friedenspaedagogik.de/images/service/basic_ne eds_400.jpg
Overwhelming Stressor Hypothesis It is my working hypothesis that the current prevention intervention model (targeted at individual education and motivation) has not worked because it targets a symptom (i.e. individual weight control) and not the core problem, overwhelming stressors. Figure: Marketing/Education www.tandl.vt.edu/VTE/MEheader.gif www.tandl.vt.edu/VTE/MEheader.gif Figure: Motivation: www.ag.ch/wov/index.htm?/wov/wov.htm www.ag.ch/wov/index.htm?/wov/wov.htm
Overwhelming Stressor Hypothesis If this hypothesis is correct, researchers will need to move from current individually oriented solutions that have not achieved obesity control in the United States to systems oriented solutions that have a better chance of working to achieve their desired outcome as has been indicated in the recent literature on the subject. This means that many uni- dimensional approaches will need to be supplanted by multi-disciplinary approaches. Figure: www.complex-systems.com/cscovers.jpg
Overwhelming Stressor Hypothesis This hypotheses intuitively explains the inability of past population level public health interventions control obesity and stop or reverse the growing obesity epidemic. This hypothesis is supported by current behavioral and other scientific information found scattered in the peer reviewed literature.
Conclusions Obesity causation and control are complex subjects. Current scientific knowledge is insufficient to provide definitive answers. The role of the built environment in obesity causation is unclear. People have numerous opportunities for recreation and to make healthy eating choices. More research is needed to identify clear cause and effect relationships sufficient to identify those built environment factors that actually result in healthier communities. The current education/motivation paradigm does not work to control obesity.
Conclusions A replacement paradigm is needed. The overwhelming stressor hypothesis is proposed. It intuitively explains field observations and is supported by technical literature. It is based on common sense and scientific evidence. What Works and other FHWA initiatives will address built environment and public health issues through the use of sound science, research, and partnerships.