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.
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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 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… Page 4 …as opposed to this? 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.ç Obesity-related policy strategies White House Task Force on Childhood Obesity (Let’s 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 Total fat Photo: examiner.com Fruits and vegetables 30% 22% 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 Low‐income 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 Map from: USDA Food Atlas Page 9 Prof. Donald Rose, Tulane University Access to healthy and unhealthy foods may influence diet Food swamps Easy access to affordable, calorie dense food? Fast food restaurants Page 10 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 Women’s 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 Page 12 Supercenters Small grocery stores 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) 2.4 3 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 Walk to the store Preference to walk to the store Who lives in the suburbs? ? Suburbs Downtown commute Budget constraints Page 17 Walk to the store 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% Whites Blacks 0% Saturated fat 9% Total fat 9% Fruits and vegetables 30% 22% 8% 54% 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? Page 20 Neighborhood buffers Also: ZIP codes, Census Tracts, Census Block Groups Page 21 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 Page 23 Alternative built environment measures: •Resources per 10,000 population •Resources per mile of road •Ratios of healthy/unhealthy resources 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 Page 27 What is a “healthy” food resource? “Healthy” “Unhealthy” Supermarkets Convenience stores Sit-down restaurants Fast food restaurants Grocery stores? 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) Page 28 *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 Availability In-store marketing Food placement Preferences Affordability Quality Financial constraints Preferences (other neighborhood food options) Skills Preferences Time constraints Preferences Thank You!!! Contact Janne Boone-Heinonen [email protected] Policy approaches to influencing dietary Intake and physical activity Targets Proximal Leverage Point Behavioral Setting Restaurant industry Restaurants Portion size Food industry & supermarket Food stores Portion size and unit packaging Employer Workplace Cafeteria Physical activity promotion policy School board School, workplace, neighborhood, recreation centers Food service Vending machines Community use of school gym, fields City government & food industry Neighborhood Fast food outlets Grocery stores City government and developers Neighborhood City government and police Page 31 Adapted from Popkin BM, unpublished Diet Physical activity Public recreation facilities Walkability Crime and perceived safety Does the built environment effect ________? Where would you •(narrow) Sidewalks •rather… Shade • Low traffic • Parks for recreation • Cul de sacs forto playdinner? •Walk •Go for a jog? • (wide) Sidewalks • Shade Why? • Dense, diverse (short distances) • Public transportation • Limited/expensive parking Page 32 An Ecological Model of Diet, Physical Activity, & Obesity Influences Health Outcomes Behaviors Biological & Demographic Age, sex, race/ethnicity, SES, genes 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 Sedentary Behaviors TV, computer use, driving Energy Balance Psychological Beliefs, preferences, emotions, self-efficacy, intentions, pros, cons, behavior change skills, body image, motivation, knowledge Physical Activity Recreation, transportation, occupation, domestic Developed for the NHLBI Workshop: Predictors of Obesity, Weight Gain, Diet, and Physical Activity; August 2004, Bethesda MD Body Weight, Fat, & Distribution Risk Factors, CVD, Diabetes, Cancers, Costs