Public health approaches to measuring the urban built environment and its effects on health: A focus on diabetes.

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2 Public health approaches to measuring the urban built environment and its effects on health: A focus on diabetes. Gillian Booth Marisa Creatore Li Ka Shing Knowledge Institute, St. Michael s Hospital Institute for Clinical Evaluative Sciences Public Health Ontario Grand Rounds, November 20, 2012

3 To appreciate: Objectives How environmental factors related to urbanization have contributed to the epidemic of type 2 diabetes To understand the impact of poverty and other contextual factors in modifying the effects of the built environment To discuss potential public health tools for measuring the built environment and its effects on health

4 Overview Neighbourhood walkability and diabetes The obesity epidemic what role do neighbourhoods play? The impact of neighbourhood walkability in Toronto Potential public health tools To measure the built environment and its health impact Potential uses of these measures in designing public health interventions to reduce obesity and diabetes Example of initiative undertaken in collaboration with Region of Peel

5 IDF The epidemic of diabetes

6 Diabetes Prevalence in Ontario Age yrs Age 50+ yrs Overall 18% 16% DM Prevalence (%) 14% 12% 10% 8% 6% 4% 5.2% 8.8% 69% 2% 0% Lipscombe L and Hux J. Lancet 2007; 369:

7 Changes in Diabetes Prevalence by Age and Sex in Ontario Change in Prevalence Rate (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Women Men Age Group (years) Lipscombe L and Hux J. Lancet 2007; 369:

8 Obesity Trends Among Canadian and U.S. Adults, 1985 No Data <10% 10%-14% 15-19% 20% =25% Mokdad AH. Unpublished Data. Katzmarzyk PT. Can Med Assoc J 2002;166:

9 Obesity Trends Among Canadian and U.S. Adults, 1990 No Data <10% 10%-14% 15-19% 20% =25% Mokdad AH. Unpubliahed Data. Katzmarzyk PT. Can Med Assoc J 2002;166:

10 Obesity Trends Among Canadian and U.S. Adults, 1994 No Data <10% 10%-14% 15-19% 20% =25% Mokdad AH, et al. J Am Med Assoc 1999;282:16. Katzmarzyk PT. Can Med Assoc J 2002;166:

11 Obesity Trends Among Canadian and U.S. Adults, 1996 No Data <10% 10%-14% 15-19% 20% =25% Mokdad AH, et al. J Am Med Assoc 1999;282:16. Katzmarzyk PT. Can Med Assoc J 2002;166:

12 Obesity Trends Among Canadian and U.S. Adults, 1998 No Data <10% 10%-14% 15-19% 20% Mokdad AH, et al. J Am Med Assoc 1999;282:16. Katzmarzyk PT. Can Med Assoc J 2002;166:

13 Obesity Trends Among Canadian and U.S. Adults, 2000 No Data <10% 10%-14% 15-19% 20% =25% Mokdad AH, et al. J Am Med Assoc 2000;284:13. Statistics Canada. Health Indicators, May, 2002.

14 Obesity Trends Among Canadian and U.S. Adults, 2004/05 No Data <10% 10%-14% 15-19% 20% =25% =30% Provinces (measured) CCHS, 2004 Territories (self-report) CCHS, 2002

15 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or older Obesity (BMI 30 kg/m 2 ) No Data <14.0% % % % >26.0% Diabetes No Data <4.5% % % % >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

16 What s driving these trends?

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21 Environmental Influences Policy Environment Commercial Environment Built Environment Human Biology OBESITY Social / Cultural Environment

22 The Built Environment How we build our communities, transportation systems, and make use of land (e.g. green spaces for parks and public recreational space)

23 Older neighbourhoods have features that make them more walkable More dense Grid-like street pattern (shorter blocks) Mixed land use Destinations within walking distance Sidewalks

24 Suburban design discourages walking and increases reliance on cars Large lot sizes (more sprawl) Less connected streets (longer blocks) Purely residential zoning Few walkable destinations Often no sidewalks

25 More time spent in cars -> higher rates of obesity Frank LD et al Am J Prev Med 2004

26 Theoretical link between urban built environment and type 2 diabetes Walkability Healthy Resources Physical Environment Retail Food environment Walking, bicycling, other activities, food purchases Weight gain + Obesity Type 2 Diabetes

27 Theoretical link between urban built environment and type 2 diabetes Walkability Healthy Resources Physical Environment Retail Food environment Walking, bicycling, other activities, food purchases Weight gain + Obesity Type 2 Diabetes

28 Theoretical link between urban built environment and type 2 diabetes Walkability Healthy Resources Physical Environment Retail Food environment Walking, bicycling, other activities, food purchases Weight gain + Obesity Type 2 Diabetes

29 Theoretical link between urban built environment and type 2 diabetes Walkability Healthy Resources Physical Environment Retail Food environment Walking, bicycling, other activities, food purchases Weight gain + Obesity Type 2 Diabetes

30 Theoretical link between urban built environment and type 2 diabetes Walkability Healthy Resources Physical Environment Retail Food environment Walking, bicycling, other activities, food purchases Weight gain + Obesity Type 2 Diabetes

31 Neighbourhood Environments and Resources for Healthy Living: A Focus on Diabetes in Toronto

32 Activity-friendliness associated with diabetes burden More diabetes Less Activity-friendliness

33 Problem worse in high risk areas (greater levels of poverty, immigration) More diabetes Less Activity-friendliness

34 30-50, , , , ,000 Neighbourhood Environments and Resources for Healthy Living: A Focus on Diabetes in Toronto

35 Does neighbourhood walkability predict walking, other travel behaviours, or obesity in Toronto?

36 Measuring walkability Sprawling vs. compact Neighbourhoods Zoning differences Lay out of streets (short vs. long blocks; grid-like vs. curvilinear or cul-de-sacs) Population density Residential density Land use mix Walkable destinations Street connectivity

37 Creating a walkability index Sprawling vs. compact Neighbourhoods for Toronto Population density* Residential density* Zoning differences Land use mix Walkable destinations* Lay out of streets (short vs. long blocks; grid-like vs. curvilinear or cul-de-sacs) Street connectivity*

38 Characteristic (%) Q5:Q1 ratio (highest to lowest walkability score) Walk or bicycle to work 3.09 Public transit to work 1.72 Drive to work 0.57 Obesity* 0.75 *age yrs; p <.001 for all

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40 Does area walkability predict the development of diabetes in Toronto?

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42 Objectives To examine whether area walkability predicts the likelihood of developing diabetes If so, if the effect is stronger in recent immigrants

43 Many immigrants have increased risk of diabetes Female Male Age-adjusted prevalence (%) Source: Creatore et al., CMAJ, 2010.

44 Study overview Study population (age yrs) = 1,658,027 (212,882 recent immigrants) April 1, 2005 March 31, 2010 Neighbourhood walkability based on postal code of residence Diabetes based on entry into Ontario Diabetes Database (ODD)

45 Diabetes risk among men aged years by neighbourhood walkability and immigration status Booth et al., Diabetes Care, 2012

46 Diabetes risk among women aged years by walkability quintile and immigration status Booth et al., Diabetes Care, 2012

47 Age-and sex-standardized diabetes incidence by area walkability, income and immigration status Booth et al., Diabetes Care, 2012

48 Potential public health tools for measuring the built environment

49 Walkability Index Comparisons Toronto Walkability Index Walk Score Street Smart Walk Score

50 Similar associations with other walkability indices Toronto Public Health: The Walkable City, Neighbourhood Design and Preferences, Travel Choices and Health. April 2012.

51 Applying measures for planning public health interventions

52 Broader policy impact of this line of research Map diabetes prevalence rates to identify high risk communities for targeted diabetes prevention initiatives Opens up other avenues for diabetes prevention on a broader scale: Policies around zoning, urban development, transit, parks, recreational centres, food retailers, infrastructure for cycling and walking paths

53 Estimated impact of different strategies for diabetes prevention Population-level Individual-level 3.3% average weight loss in all adults Target pop = 8.2 million 4.2% average weight loss in all overweight adults Target pop = 4.1 million Intensive lifestyle in highest risk population Target pop = 369,000 33,000 New Diabetes Prevented Diabetes Population Risk Tool, Rosella et al. and Manuel et al., 2010

54 Potential policy interventions New developments: Change building standards to make neighbourhoods more walkable and activity friendly Restructuring of existing communities Re-zoning and other incentives to encourage retail, services, and other amenities to move into high need areas

55 Case Study: Peel Region Healthy Development Evaluation Tool Issue: Peel is one of Ontario s fastest growing regions Much of Peel region characterized by suburban sprawl, pedestrian-unfriendly, cardependent design

56 Region of Peel has high rates of inactivity, overweight / obesity and diabetes

57 Case Study: Peel Region Healthy Development Evaluation Tool Intervention: In March, 2009 our team contracted to create an evidence-based Tool to evaluate new land development applications in Peel Region Purpose of Tool was to encourage future development to proceed in a form more conducive to healthy living with a focus on physical activity

58 Case Study: Peel Region Healthy Development Evaluation Tool Process Step 1: Literature review conducted on health and built environment research, grey literature and best practices articles Evidence from review used to create: Elements (or categories); e.g., Density. Measures (or quantifiable components within categories); e.g., net residential density. 'Strength of Evidence' used to determine: Inclusion in Tool or not Prerequisite or Credit

59 Case Study: Peel Region Healthy Development Evaluation Tool Process Step 2: 1) Consultation with stakeholders i. Roundtables with municipal and regional planners, as well as private planning consultants ii. Expert consultation/review 2) Gap analysis i. Compared existing standards with recommended standards (according to the Tool )

60 Case Study: Peel Region Healthy Development Evaluation Tool Process Step 3: GIS Validation of Tool i. Validated Tool against existing Peel communities

61 Case Study: Peel Region Healthy Development Evaluation Tool Final Format of the Tool 7 Built Environment Elements associated with active living: Density Service Proximity Land Use Mix Street Connectivity Road Network and Sidewalk Characteristics Parking Aesthetics and Human Scale Dunn, J. et al. (2009). Peel healthy development evaluation tool.

62 Case Study: Peel Region Healthy Development Evaluation Tool Three key findings emerged: 1) Developers and builders have limited discretion over many built environment elements that contribute to healthy development a) Directly controlled or restricted by regulatory system (By-laws, official plans) b) Driven by Market conditions (by public demand/knowledge)

63 Case Study: Peel Region Healthy Development Evaluation Tool Key Findings (cont d) 2) Significant inconsistencies exist between municipal and regional development standards (e.g., by-laws, Official Plans), planning and other departments and healthy development targets Eg. Traffic safety & efficiency vs. activityfriendliness

64 Case Study: Peel Region Healthy Development Evaluation Tool Key Findings (cont d) 3) The built environment measures used in published research are not always easily adaptable to practical use by institutions that enforce standards

65 Case Study: Peel Region Healthy Development Evaluation Tool Overall Recommendations: a) Prioritize overall public health in both transportation and urban planning using a comprehensive approach Must incorporate and align all levels of the regulatory system b) Make a commitment to healthier urban development as a 'greater good' (e.g., public safety, economic, environment) not just to walkability

66 Case Study: Peel Region Healthy Development Evaluation Tool How do we achieve these goals? Will take multi-pronged approaches, but as a start: a) Revise planning and transportation standards (e.g., by-laws, Urban Design Guidelines) so that they are consistent with recommended prerequisites allowing developers to meet both health and policy standards simultaneously b) Use a comprehensive, multi-sectoral approach to resolve inconsistencies between standards across all levels of government, between municipalities and between departments that restrict healthy urban development

67 Peel Region Healthy Development Policy Impacts: Evaluation Tool Amendments to Regional and Municipal Official Plans requiring health impact indicators and assessments as well as encouraging public awareness (ROPA 24, Town of Caledon Official Plan Amendment 226) Amendments to engineering standards to increase walkability and active transportation, and proposed changes to provincial policy statements (Provincial Policy Statement 5-year review) Integration of health background studies at the earliest stage of planning as part of a complete development application (ROPA 25) Feb 2012 resolution by Town of Caledon council to reference the PHDI for all future development expansion

68 Peel Region Healthy Development Evaluation Tool As far as we know, the Region of Peel is the first jurisdiction in North America to create a process for screening land development applications to promote healthy built environments

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70 Summary Diabetes is increasing in prevalence Look to diabetes prevention to prevent the downstream consequences of this epidemic Multifaceted approach aimed not only at individuals but also the neighbourhoods in which we live Interventions targeting the built environment that encourage physical activity may have tangible health benefits for the population

71 Built environment and diabetes Gillian Booth (co PI) Rick Glazier (co PI) Flora Matheson Rahim Moineddin Peter Gozdrya Jonathan Weyman Marisa Creatore Ghazal Fazli Jane Polsky Maria Chiu Jim Dunn, McMaster Doug Manuel, OHRI Nancy Ross, McGill Jack Tu, ICES Public Health Ontario Region of Peel Toronto Public Health

72 Questions?