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.

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 Efforts on the Built
Environment and Public Health
FHWA's Transportation Planning & Physical
Activity Project.
FHWA’s 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 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
Children’s 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/ACITAPIT/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.secondhandmobilephones.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/Mar2004/040308D-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/Mar2004/040308D-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-atwork/worksafe/action/hazardmanagement/people/stress/)
Figure:
www.defenselink.mil/news/Mar2004/040308D-6570C-014.jpg
Evidence: Longer Working
Hours
According to a study
by the National Sleep
Foundation, the
average employed
American works a 46hour work week; 38%
of the respondents in
their study worked
more than 50 hours
per week.
(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)
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)
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/injuryprevention/safe-atwork/worksafe/action/hazardmanagement/people/stress/)
Figure:
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-andbeverages-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/473Couch-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)
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)
Figure: www.texmed.org/images/stressors.gif
Evidence: Coping Results in
Chronic Stress and Fatigue
1.
2.
3.
4.
5.
The Stress Process
Stress leads to
emotional response.
Person selects a coping
response.
If effective, relaxation of
arousal.
If ineffective, arousal
increases, resulting in
strain.
Unresolved stress leads
to burnout.
(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.stjohns.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)
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
Figure: Motivation:
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 unidimensional 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.