Coming to consensus on policy to create supportive built environments and community design.

Raine, Kim D. ; Muhajarine, Nazeem ; Spence, John C. 等

In April 2011, a consensus conference was held with invited experts from research, policy and practice fields. The conference aimed to build consensus around policy levers to address environmental determinants of obesity, including next logical steps toward further policy action. We identified a range of opportunities for action, based upon a synthesis of international recommendations, best evidence from the literature and previous priority-setting within the Canadian policy milieu; (1-3) creating supportive built environments for healthy active living was one opportunity discussed. We invited conference participants to share with the group high-level insights from their experience (available political opportunities/appetite for change) and research (evidence of what works/does not work). Consensus was reached through facilitated discussion following presentation of evidence and the environmental context. A consensus paper was drafted and circulated for revision. This commentary represents a consensus of next actions towards creating supportive built environments for healthy active living.

Policy environment

"The built environment is part of our physical surroundings and includes the buildings, parks, schools, road systems, and other infrastructure that we encounter in our daily lives". (4) The built environment may influence the behaviour or weight status of populations by decreasing opportunities for physical activity, increasing opportunities to be sedentary, increasing exposure to high-energy, low-nutrient density foods, limiting access to healthy foods, and exposing people to stressors that may moderate how energy intake and expenditure relate to weight status. For example, design elements that include road network patterns leading to increased connectivity and safety, pedestrian accessibility, mixed land use, parks and playgrounds contribute to the walkability of a neighbourhood and have a tremendous impact on levels of physical activity, especially with respect to active transportation and play. (5) Residential density and zoning bylaws contribute to community design and access to opportunities for both physical activity and healthy eating.

Many Canadian jurisdictions are acknowledging a need for changes to built environments, including zoning and bylaws, to promote healthy weights. (6) According to the 2011 Active Healthy Kids Canada (AHKC) Report Card, (5) "In the past year, there has been a rise in the number of communities and governments taking this multi-sectoral/level approach in their strategies to promote child and youth physical activity and reduce sedentary pursuits by targeting the built environment" (p. 46). Yet, the same 2011 AHKC report card disclosed that only 16% of municipalities had a formal transportation master plan and less than 20% of communities required mandatory safe walking and biking routes in the development of new areas, reconstruction of roads or retrofitting of existing communities. In 2008, the AHKC reported that 96% of

Canadian municipalities had at least one bylaw discouraging physical activity or free play, such as restrictions on skateboarding, street hockey or bicycling. (7) The inherent contradiction is that municipal bylaws emphasizing safety from injury (safe play) function to counter promotion of an active lifestyle as part of well-being. The yawning gap between existing policy tools at the municipal level and what we acknowledge as increasingly necessary to promote active lifestyle through community design is a major policy opportunity that needs to be addressed.

Recent surveys of decision-makers from all levels of government, schools and workplaces in Alberta show support for policy initiatives that address land-use design and zoning to promote active living, but to a lesser degree to promote healthy eating. Respondents supported implementing transportation policies designed to promote physical activity through safe routes, cycle facilities, adequate lighting, etc. (89%); enhancing the quantity and quality of green spaces in all neighbourhoods (93%); changing the design of our neighbourhoods and communities to encourage informal physical activity in daily life (85%); and changing building and community design standards to discourage sedentary activities (63%). The same survey found little support for using land-use decisions and zoning to promote healthy eating. In fact, a large albeit minority proportion of respondents (46%) supported zoning to increase the number of small grocery stores at walking distance from residences in every neighbourhood, and only 28% supported zoning to limit fast food restaurants per square kilometre. (8)

Public opinion, however, is generally much more positive about such measures, 56% of Albertans surveyed indicating their support for zoning to limit fast food restaurants per square kilometre, and 74% reporting support for zoning to restrict the supply of junk food near schools. (9) Similarly, 72% of respondents in Quebec claimed they were supportive, in principle, of restrictions on fast food outlets near schools. The support increases to 83%-87% when the possibility of actually adopting regulatory measures is proposed. (10)

Evidence

A systematic review has reported evidence for associations between built environment and diet, physical activity and sedentary behaviour. (6) However, while systematic reviews of epidemiologic studies of the built environment and obesity have found statistically significant associations in approximately half of the studies reviewed, heterogeneity across studies limits the strength of evidence. (11)

Looking specifically at Canadian studies, including those in this supplement, different aspects of the built environment appear to be related to obesity and its proximal determinants in varied urban contexts. Specifically, in Toronto, residential density has been associated with decreased population obesity, and in Vancouver, residential density, land-use mix, street connectivity and a composite walkability index are all associated with decreased population obesity among adults. (12) In Ottawa, neighbourhoods with fewer recreation opportunities were associated with higher body mass index (BMI) among adults. (13)

The results emerging from built environment studies specifically focusing on children point to a more complex picture. In Saskatoon, children 10-14 years of age living in fractured-grid neighbourhoods accumulated less physical activity and more sedentary time per day than those in grid-pattern or curvilinear-pattern neighbourhoods. (14) Studies from Halifax and Toronto in this issue further elucidate the potential mitigating effects of neighbourhood level socio-economic status. A study of children 12-14 years of age in Halifax reported that rates of physical activity in children from schools in lower socio-economic areas were higher in urban than in suburban or rural settings. (15) In Toronto, children who attended schools in more affluent neighbourhoods had more positive physical activity profiles across the week. (16)

The findings on the effect of the built environment on children's physical activity and obesity reported in this issue extend the results from several earlier studies conducted in Canadian cities. Studies from Edmonton have reported that a walkable neighbourhood design, specifically intersection density, was associated with decreased childhood obesity among girls. (17) Among pre-adolescent children in Alberta, neighbourhood safety, sidewalks and parks are negatively correlated with body weight. (18) Further, an Ontario study revealed that children with a park playground within 1 km from home were five times more likely to be at healthy weight than children without such access. (19) Studies have shown that children who live in neighbourhoods with fewer amenities or lacking neighbourhood access to sidewalks, walking paths, parks or playgrounds, or recreation or community centres had 20%-45% higher odds of being obese/overweight. (20) These findings are supported by a study in this issue from London, ON, which reports that public recreation opportunities within a 500-metre network distance from home were associated with lower BMI in children. (21)

Perceptions of built environment are also important. In Edmonton, children aged 6 to 12 described more active transportation in their neighbourhoods when they lived in highly walkable areas. (22) Among adults in Edmonton, neighbourhood choice (for ease of walking) was associated with a lower BMI, whereas objectively measured walkability was not a significant influence on BMI. (23) Perceptions of traffic as a barrier to walking also predicted higher BMI. (24)

Community design, zoning and neighbourhood social factors are also associated with physical access to foods. For example, Canadian research has found that fast food outlets are more prevalent in neighbourhoods of lower socio-economic status, (25) while supermarkets--sources of wider food choices, including healthy foods are less prevalent in these neighbourhoods. (26) A Montreal study reported in this issue found that children attending a school in neighbourhoods with a higher number of unhealthy relative to healthy food establishments scored most poorly on dietary outcomes. (27) Additionally, a study in Halifax found that dietary quality was higher among youth in higher than in lower socio-economic urban settings. (15) Further, there was evidence from an Edmonton study that the shorter the distance to healthier food sources from one's residence, the less the likelihood of obesity. (28) With regard to the influence of neighbourhood food environment on healthy eating among grade 7 and 8 students in London, ON, the proximity of convenience stores to students' homes and proximity of schools to convenience stores and fast food outlets were all significantly associated with decreased healthy eating index scores. (29)

Evidence of the impact of the built environment on behaviours and weight status is growing. There are small but meaningful associations observed between aspects of the built environment and behavioural determinants/risk of obesity, although the findings are inconsistent. Perceptions of the environment may be as important as objectively measured aspects of environments. Over the past four years, the Heart and Stroke Foundation and Canadian Institutes of Health Research have made research on obesity and built environment a strategic focus, and several Canadian research projects have been funded that contribute to the evidence base; several of those studies are reported in this supplement. Yet, evidence on the effectiveness of built environment interventions is sparse. Very little intervention research has linked the effectiveness of changing environments to behavioural or weight and health outcomes, especially in a policy context, (6) suggesting a serious evidence gap.

Issues and challenges

Changing the built environment significantly is a massive undertaking with potentially huge financial investment needs Building transportation infrastructure is a significant investment that spans jurisdictions' decision-making structures and involves sectors not traditionally involved with health. For example, building a road may be primarily a provincial responsibility, yet incorporating bike lanes or increasing public transit may be a municipal one. Urban planners with municipal mandates may face challenges as to what they can accomplish, as provincial laws and policies may be outdated or too restrictive. Physical activity, food access and health may not yet be a high priority for transportation and planning sectors or even for departments of finance. Indeed, given the multiple demands on limited municipal tax bases, finding sufficient resources to maintain, change or build infrastructure supportive of health-promoting community design may be a challenge.

Smaller, localized changes in built environments may provide the opportunity for incremental changes

Focusing on school environments or municipal bylaws is not only more manageable politically and practically, but can also provide preliminary evidence of local effectiveness as exemplars for others.

Public support for change in built environments may need to take into account parental concerns about child safety

Enhancing safety (i.e., fewer traffic incidents involving pedestrians and cyclists) through improved built environmental design may have more immediate resonance with parents than changes in health status or obesity. Social perceptions, such as parental fears about child safety (i.e., child abduction by strangers, which is extremely rare), are significant factors that need to be taken into account when promoting built environment changes. Connecting issues of violence prevention with safety challenges, dispelling myths and fears, and engaging public support for change should not further exacerbate public fears but, rather, help to dispel them.

Recommendations

To create supportive built environments that encourage physical activity, active living and access to healthy foods in local communities, we recommend the following:

* Empower local planning authorities to

--change bylaws that have an effect of restricting physical activity

--initiate programs to help protect and increase access to green space, including parks and playgrounds

--introduce zoning bylaws that increase high density and mixed land use

--through a combination of incentives (tax shelters) and constraints (zoning bylaws) influence the location and distribution of food stores, including fast food stores and suppliers of fruit and vegetables.

* Establish stable, long-term funding for municipal infrastructure that promotes active transportation and provides opportunities and facilities for recreation.

* Evaluate the effectiveness of local programs in improving aspects of the built environment so that successful intervention strategies can be identified and scaled up.

--Evidence of what interventions work under which conditions is likely to come from natural experiments assumed by committed communities based on the growing evidence associating built environment with obesity and health.

--It is essential for researchers to work with planners and policymakers to capture the impact of local changes.

* Make health impact assessment of planning, development and transportation policies mandatory to ensure that legislative changes increase walking, cycling and safety for children and citizens.

--As the impact of the built environment, including land use and community design, on the health of the population becomes increasingly evident, promoting the development and implementation of public policies conducive to health suggests consideration of the health impacts of new and standing policies in major project planning.

--Development of tools to assist municipalities and provincial jurisdictions in doing such assessments is required.

* Advocate the framing of issues so as to dispel myths and fears about child safety (from abduction or injury) and to promote child safety from obesity risk factors (e.g., physical inactivity, sedentary behaviours).

CONCLUSION

Consensus around policy levers to address environmental determinants of obesity, including next logical steps toward further policy action, led to concrete recommendations for researchers, practitioners and policy-makers to create supportive built environments that encourage physical activity, active living and access to healthy foods in local communities.

Conflict of Interest: None to declare.

Acknowledgements: This research was funded by a Meeting, Planning and Dissemination grant from the Canadian Institutes of Health Research (CIHR). K. Raine acknowledges an Applied Public Health Chair Award from the Heart and Stroke Foundation and CIHR. The authors thank Manuel Arango, Susan Buhler, Timothy Caulfield, Diane Finegood, Samantha Hartley-Folz, Bill Jeffery, Jane Landon, Craig Larsen, Tim Lobstein, Lyne Mongeau, Suzie Pellerin, Lisa Petermann, Monique Potvin Kent, Shandy Reed and Michele Simon for their participation in the consensus conference.

REFERENCES

(1.) Alberta Policy Coalition for Cancer Prevention. Our Focus [online]. 2011. Available at: http://abpolicycoalitionforprevention.ca/our-focus.html (Accessed July 30, 2011).

(2.) The Canadian Partnership Against Cancer. Canadian Priorities for Addressing Obesity as a Cancer and Chronic Disease Risk Factor. Toronto, ON: Nutrition and Physical Activity Policy Alignment in Action Initiative, 2010.

(3.) Heart and Stroke Foundation. Community Design, Physical Activity, Heart Disease and Stroke. 2012. Available at: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3820627/k.662E/Position_Statements__Community_Design_physical_activi y_heart_disease_and_stroke.htm (Accessed June 12, 2012).

(4.) Health Canada. Natural and Built Environments. Ottawa, ON: Division of Childhood and Adolescence, 2002.

(5.) Active Healthy Kids Canada. Don't Let This Be the Most Physical Activity Our Kids Get After School: The Active Healthy Kids Canada 2011 Report Card on Physical Activity for Children and Youth. Toronto, ON: Active Healthy Kids Canada, 2011.

(6.) Raine K, Spence JC, Church J, Boule N, Slater L, Marko J, et al. State of the Evidence Review on Urban Health and Healthy Weights. Ottawa, ON: Canadian Institute for Health Information, 2008.

(7.) Active Healthy Kids Canada. Canada's Report Card on Physical Activity for Children and Youth. Toronto, ON: Active Healthy Kids Canada, 2008.

(8.) Alberta Policy Coalition for Cancer Prevention. APCCP Survey Results for Healthy Eating, Active Living, Alcohol Misuse and Tobacco Reduction Issues: Decision-Maker Survey of Knowledge, Attitudes and Beliefs. Edmonton, AB: Alberta Policy Coalition for Cancer Prevention, 2009.

(9.) Alberta Policy Coalition for Cancer Prevention. Alberta Survey of Knowledge, Attitudes, and Beliefs. Edmonton, AB: Alberta Policy Coalition for Cancer Prevention, 2010.

(10.) Association pour la sante publique du Quebec. The School Zone and Nutrition: Courses of Action for the Municipal Sector. Montreal, QC: Association pour la sante publique du Quebec, 2011.

(11.) Feng J, Glass TA, Curriero FC, Stewart FC, Stewart WF, Schwartz BS. The built environment and obesity: A systematic review of the epidemiologic evidence. Prev Med 2009;16(2):175-90.

(12.) Pouliou T, Elliott SJ. Individual and socio-environmental determinants of overweight and obesity in urban Canada. Health & Place 2010;16(2):389-98.

(13.) Prince SA, Tremblay MS, Prud'homme D, Colley R, Sawada M, Kristjansson E. Neighbourhood differences in objectively measured physical activity, sedentary time and body mass index. Open J Prev Med 2011;1(3):182-89.

(14.) Esliger D, Sherar L, Muhajarine N. Smart cities, healthy kids: The association between neighbourhood design and children's physical activity and time spent sedentary. Can J Public Health 2012;103(Suppl. 3):S22-S28.

(15.) Shearer C, Blanchard C, Kirk S, Lyons R, Dummer T, Pitter R, et al. Physical activity and nutrition among youth in rural, suburban and urban neighbourhood types. Can J Public Health 2012;103(Suppl. 3):S55-S60.

(16.) Stone MR, Faulkner GE, Mitra R, Buliung RN. Physical activity patterns of children in Toronto: The relative role of neighbourhood type and socioeconomic status. Can J Public Health 2012;103(Suppl. 3):S9-S14.

(17.) Spence JC, Cutumisu N, Edwards J, Evans J. Influence of neighbourhood design and access to facilities on overweight among preschool children. Int J Pediatr Obes 2008;3:109-16.

(18.) Davidson Z, Simen-Kapeu A, Veugelers P. Neighborhood determinants of self-efficacy, physical activity, and body weights among Canadian children. Health & Place 2010;16(3):567-72.

(19.) Potwarka LR, Kaczynski AT, Flack AL. Places to play: Association of park space and facilities with healthy weight status among children. J Community Health 2008;33(5):344-50.

(20.) Singh GK, Siahpush M, Kogan MD. Neighborhood socioeconomic conditions, Built environments, and childhood obesity. Health Aff (Millwood) 2010;29(3):503-12.

(21.) Gilliland JA, Rangel CY, Healy MA, Tucker P, Loebach JE, Hess PM, et al. Linking childhood obesity to the built environment: A multi-level analysis of home and school neighbourhood factors associated with body mass index. Can J Public Health 2012;103(Suppl. 3):S15-S21.

(22.) Holt NL, Cunningham CT, Sehn ZL, Spence JC, Newton AS, Ball GD. Neighborhood physical activity opportunities for inner-city children and youth. Health & Place 2009;15:1022-28.

(23.) Berry TR, Spence JC, Blanchard CM, Cutumisu N, Edwards J, Selfridge G. A longitudinal and cross-sectional examination of the relationship between reasons for choosing a neighbourhood, physical activity and body mass index. Int J Behav Nutr Phys Act 2010;7(1):57.

(24.) Berry T, Spence J, Blanchard C, Cutumisu N, Edwards J, Nykiforuk C. Changes in BMI over 6 years: The role of demographic and neighborhood characteristics. Int J Obes 2010;34(8):1275-83.

(25.) Hemphill E, Raine K, Spence JC, Smoyer-Tomic KE. Exploring obesogenic food environments in Edmonton, Canada: The association between socioeconomic factors and fast-food outlet access. Am J Health Promot 2008;22(6):426-32.

(26.) Smoyer-Tomic KE, Spence JC, Raine KD, Amrhein C, Cameron N, Yasenovskiy V, et al. The association between neighborhood socioeconomic status and exposure to supermarkets and fast food outlets. Health & Place 2008;14(4):740-54.

(27.) Van Hulst A, Barnett TA, Gauvin L, Daniel M, Kestens Y, Bird M, et al. Associations between children's diets and features of their residential and school neighbourhood food environments. Can J Public Health 2012;103(Suppl. 3):S48-S54.

(28.) Spence JC, Cutumisu N, Edwards J, Raine KD, Smoyer-Tomic K. Relation between local food environments and obesity among adults. BMC Public Health 2009;9(1):192.

(29.) He M, Tucker P, Gilliland J, Irwin JD, Larsen K, Hess P. The influence of local food environments on adolescents' food purchasing behaviors. Int J Environ Res Public Health 2012;9:1458-71.

Kim D. Raine, PhD, RD, [1] Nazeem Muhajarine, PhD, [2] John C. Spence, PhD, [3] Neil E. Neary, MPH-HP, [1] Candace I.J. Nykiforuk, PhD [1]

Author Affiliations

[1]. Centre for Health Promotion Studies, School of Public Health, University of Alberta, Edmonton, AB

[2.] Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, SK

[3.] Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB

Correspondence: Kim D. Raine, Edmonton Clinic Health Academy #3-291, 1140587th Ave. NW, Edmonton, AB T6G 1C9, Tel: 780-492-9415, Fax: 780-492-0364, E-mail: kim.raine@ualberta.ca