This document discusses the relationship between the built environment and public health. It provides statistics showing that driving is associated with negative health outcomes, while walking and biking are beneficial. Rates of obesity, diabetes, and other chronic diseases have increased as communities have been designed primarily for automobiles. Redesigning cities and neighborhoods to encourage physical activity, such as by building light rail systems and removing freeways, can significantly improve health. The built environment is now recognized as a major determinant of public health.

1. Richard J Jackson MD, MPH, FAAP
HonASLA, HonAIA
dickjackson@ucla.edu
Oklahoma Must Walk to Health
April 3,2013
University of Oklahoma

2. http://designinghealthycommunities.org/oram/

4. USA Today 10/20/2011

5. Commuting by driving is not good for your
physical, mental, and social health.
Traffic along LA freeways and Wilshire Blvd.

6. We Pediatricians Fear This Most In
Our Own Children…

7. For every age group
from 3 through 34—car
crashes were the No. 1
cause of death

8. In 2009 in the US
2,953,501million vehicle miles traveled
33,808 people died
in motor vehicle traffic crashes.
One in a million chance of death per
every 87 miles driven
• http://www.fhwa.dot.gov/policyinformation/statistics/2009/vm1.cfm
• http://www-nrd.nhtsa.dot.gov/Pubs/811363.PDF

9. Automobile fatality rates by city, 1998
(excluding pedestrian fatalities; deaths/100,000/year)
9.80
10.52
11.33 13.12
Source: NHTSA
2.51
New York
3.76
San Francisco
6.55
Portland
9.80
Houston
10.52
Phoenix
11.33
Dallas
13.12
Atlanta
5.36
Philadelphia

10. Number of Lives Saved per year
if National Car Fatality Rate same as:
• New York City 24,000
• Portland 15,000
• Atlanta None– 15,000 additional

11. Average pedestrian fatality rates by city, 1996-2004
(deaths/100,000/year)
Source: FARS Analysis Reporting System, NHTSA
2.29
New York
3.43
San Francisco
2.42
Portland
2.63
Houston
4.06
Phoenix
3.39
Dallas
4.91
Atlanta
2.36
Philadelphia
Source: Calculated from annual summary of traffic fatalities published by the National Highway Traffic
Safety Administration in Traffic Safety Facts.

12. Pedestrian Danger Index, 2002-2003
Source: Mean Streets 2004
33.4
New York
49.4
San Francisco
43.0
Portland
121.9
Houston
117.2
Phoenix
103.7
Dallas
144.4
Atlanta
48.3
Philadelphia
Source: Ernst, M. Mean Streets 2004: How far have we come? Surface Transportation Policy
Project, November 2004. Accessed online at http://www.transact.org/report.asp?id=235 on Oct 4,
2006.

13. Pedestrian Fatality Rates for
Collisions at Different Speeds
Zegeer et al 2002

14. The Most Prevalent Chronic
Disease of Childhood Is…

15. Asthma Study in 12 Southern
California High Schools
• 3535 children with no history of asthma in 6
high and 6 low air pollution high schools
• 5 years later: 265 children developed asthma.
– High ozone high schools:
• asthma rate was 3.3x higher in children playing
three or more sports.
– Low ozone high schools:
• sports had no effect on asthma rates

16. 30% reduction in Driving
30 % Improvement in Air
Quality

17. Results: Acute Care Visits for Asthma
1-16 year old residents of Atlanta
0
1
2
3
4
5
6
Medicaid Claims* Kaiser HMO Pediatric ER's Hospital Admissions
Baseline Period Olympic Period†
MeanDailyNumberofEvents
•p = 0.01
† July 19 –August 4, 1996
Source: Friedman, et al, JAMA, 2001

18. Did you Hear about Carmageddon?
When the 405 Freeway in LA Was
Closed for a Weekend in 2011?

19. Air Quality Change During Carmageddon
Close to the Highway Improved 83%
In West Los Angeles and Santa Monica Improved 75%
For the Region Improved 25%
2 day closure
of 10 miles of
Highway 405
in July 2011

20. “I like to play indoors
better ’cause that’s
where all the electrical
outlets are,”
-fourth grader.

21. New York Times
March 31, 2013
CDC Data
20% of Teen Age
boys taking
Diagnosed with
Hyperactivity

23. • The Built
Environment:
Designing
Communities to
Promote Physical
Activity in
Children
• Policy Statement
American
Academy of
Pediatrics
• June 2009

25. Obesity Trends* Among U.S. Adults
BRFSS, 1991(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

26. Obesity Trends* Among U.S. Adults
BRFSS, 1997(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%

27. Obesity Trends* Among U.S. Adults
BRFSS, 2009(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

28. Obesity Trends* Among U.S. Adults
BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

29. NHANES -- Measured
NHANES – In person interview-- self-reported
BRFSS – Telephone Interview
Body Mass Index US Females 1988-1994

30. • …by 2030
obesity rates will
rise to 42%
• The US will need
to care for …
32 million more
obese people
than in 2010.
Forecast:
by 2030 the prevalence of the US
population with a BMI over 40 (~100 pounds
overweight) will be 11%

31. 0
25
50
75
100
Relationship Between BMI and Risk
of Type 2 Diabetes
Chan J et al. Diabetes Care 1994;17:961.
Colditz G et al. Ann Intern Med 1995;122:481.
Age-AdjustedRelativeRisk
Body Mass index (kg/m2
)
WomenWomen
MenMen
<22 <23 23
-
23.9
24
-
24.9
25
-
26.9
27
-
28.9
29
-
30.9
31
-
32.9
33
-
34.9
35+
1.0
2.9
1.0
4.3
1.0
5.0
1.5
8.1
2.2
15.8
4.4
27.6
40.3
54.0
93.2
6.7
11.6
21.3
42.1

32. Percentage of US Adults with Diagnosed
Diabetes - 1994

33. Percentage of US Adults with Diagnosed
Diabetes - 2007

34. U.S. “Health” Care
Expenditures as Percent of
GDP
Keehan et al: Health Affairs
March/April 2008 27: 145-155

35. Male Life Expectancy
US Life Expectancy is #49 Worldwide – CIA Chartbook

36. “The Status of
Baby Boomers’
Health in the
United States:
The Healthiest
Generation?”
JAMA Internal
Medicine
February 4, 2013

37. Overall Health Status US
Persons Aged 46-64
NHANES 1988-1994 NHANES 2007-2010
Report “excellent” health
32% 13%
“Functional Limitation”
9% 14%
Using Walking Assist (wheelchair, cane, etc)
3% 7%

38. “Lifestyle Factors” US
Persons Aged 46-64 (NHANES)
1988-1994 2007-2010
Smoking
28% 21%
Obesity
29% 39%

39. “Lifestyle Factors” US
Persons Aged 46-64 (NHANES)
1988-1994 2007-2010
Smoking
28% 21%
Obesity
29% 39%
No Regular Physical Activity
17% 52%

40. 1
0
0.5
1
1.5
2
Lean Obese
Risk of Death
Active
Hu et al. NEJM, December 23, 2004; 351(26):2694-2703.
Nurse Study 1976-2000

41. 1
1.9
0
0.5
1
1.5
2
Lean Obese
Risk of Death
Active
Hu et al. NEJM, December 23, 2004; 351(26):2694-2703.
Nurse Study 1976-2000

42. 1
1.6
1.9
0
0.5
1
1.5
2
Lean Obese
Risk of Death
Active
Inactive
Hu et al. NEJM, December 23, 2004; 351(26):2694-2703.
Nurse Study 1976-2000

43. 1
1.6
1.9
2.4
0
0.5
1
1.5
2
2.5
Lean Obese
Risk of Death
Active
Inactive
Hu et al. NEJM, December 23, 2004; 351(26):2694-2703.
Nurse Study 1976-2000

44. Gain in Longevity for a 45-Year Old Male
5.8 years
8.7 years
0
2
4
6
8
10
Low vs Moderate Low vs High
Years of added life
Additional years of Life:
Moving from Low to Moderate Fitness -- 5.8 years
From Low to High –- 8.7 years.

45. Credit: Hummel Architects, Boise, ID
“Old”
Schools
Credit: Manitovic Public School District

46. Schools
• Since World War II
–Average School Size
• grew fivefold, from 127 to 653 students
• Number of Schools declined 70%
Credit: Constance E. Beaumant, NTHP

47. • Percent of
children who
walk or bike to
school:
• 1974  66%
• 2000  13%
(CDC, 2000)
We have changed
how much we
walk or bike

48. Fitness of California Children
Annual Fitnessgram Results
Conducted in Grades 5, 7, and 9
Measures 6 major fitness areas
(e.g. aerobic capacity, body composition, flexibility)
2011 Results: Who passed all standards?
Grade 5: 25%
Grade 7: 32%
Grade 9: 37%
http://www.cde.ca.gov/nr/ne/yr11/yr11rel95.asp#tab1

49. Institute of Medicine
Report
Accelerating Progress
in Obesity Prevention
May 8, 2012

51. Complete Streets Bring Equity to
Community and Transportation
• Complete Streets
– social equity, aesthetics, walking, improved
local sales, community building

52. • Sonoma county:
General Plan
--Policies that
Address Public
Health Threats

53. APHA National Meeting 2002-2003
Abstracts with “land use” - 0
2002 2003
A Big Shift in Public Health’s Awareness of Built
Environment as a Core Determinant of Health

54. 2011 APHAAnnual Meeting
“land use” 102 matches
“built environment”
182 matches

55. Bicycle Rental Area Outside Union Station Washington, DC

56. Two Police “vehicle” parked durng lunch

57. ic
• Average ~200 kcal/hr
• Cost of Police Mountain Bike
– $700-1000
• Average ~ 650/kcal/hr
• Segway Personal Transporter
• $5000 and up

58. Charlotte, NC, Light Rail Opened
November, 2007

59. Interviewed
People at 839
Locations
years before
and after
Charlotte
Light Rail
Service Began

61. • Significant increase in meeting the
weekly Recommended Physical
Activity
• … through walking
• …and through vigorous exercise

62. • The use of Light Rail Transit to commute to
work was associated with an average
reduction of 1.18 BMI points (p<0.05) and
81% reduced odds of becoming obese over
time.
• For a person who is 5’5” --equivalent
to a relative weight loss of 6.45 lbs.

63. The Need for Health Impact
Assessment (HIA)
• Big decisions are made without examining
potential health impacts (both positive and
negative) over the life cycle.

64. Cooper River Bridge
Charleston SC
• If you build a walkway on a major bridge, how
many pedestrians and bicyclists will use it?

65. Walkway on Cooper River Bridge,
Charleston SC

66. • The Chenoggye freeway ran through the
center of Seoul ~1970-2005

67. • Cheonggyecheon -- 8.4 km long downtown Seoul, South Korea.
• The $900 million project initially attracted much public criticism.

70. http://www.grist.org/article/2010-08-26-when-streets-tell-the-truth-about-people-riding-in-cars-bikes/

71. Richard J Jackson MD MPH
dickjackson@ph.ucla.edu
We Are What We Eat, and…
We Are What We Build!