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Obesity has become such an epidemic in America that some doctors are asking for help from government --- and it has nothing to do with diet. They want better-designed communities.
Because development is regulated through the local planning and zoning process, some health officials say, elected leaders can make an impact on the public's health.
"The purpose of public health is to provide the conditions where people can be healthy," said Richard Jackson, a pediatrician and a senior adviser at the federal Centers for Disease Control and Prevention who speaks across the country about the sprawl-health connection. "For too long, the health community started at the end of the disease. We were derelict in looking at what are the typical causes of these problems."
For example, developments that include sidewalks and nearby places to walk to such as coffee shops and grocery stores can encourage people to exercise --- even casually --- and can help in the war against obesity, he said.
Yet others contend that government shouldn't interfere with how people choose to live by mandating less-sprawling communities.
"I think that the government's goal is to maximize our happiness --- usually by letting us freely make our own decisions --- not to force us to be healthier than we want to be," said Edward L. Glaeser, an urban economist at Harvard University.
Much of the emerging debate about links between public health and community design is happening in Atlanta, considered the poster child for suburban sprawl. It's home to the CDC and a school of public health at Emory University. Data gathered from 17,000 Atlanta area residents are being used by former Georgia Tech professor Lawrence Frank to assess land-use and transportation effects on health. Emory and Georgia Tech are considering the creation of a joint degree program in planning and public health.
Some metro area residents also are testing the theory that if people have easy ways to start or maintain a healthy lifestyle, they're more likely to try it.
Retirees Carolyn and Norman Daniels moved from Augusta to Silver Springs Village, a subdivision in Powder Springs marketed to those 55 and older. It's located steps away from the Silver Comet Trail, a converted railroad line that runs from Cobb County to Alabama. The trail was not a draw, but now it has become part of their routine.
Norman Daniels, 67, says he cycles once a week on the trail. "I hadn't used that bike in how many years?" he asked his wife. "Six or seven or eight?"
Before their relocation eight months ago, Carolyn Daniels, also 67, said she exercised only sporadically, mostly with a stationary bike in her bedroom.
"It gets boring," she said.
But now that she lives next to the trail, she walks three times a week with other women from the neighborhood. Her friend Earline Pettet, 64, walks from the subdivision to the nearby Powder Springs Post Office. Other Silver Springs Village residents walk to the grocery and downtown Powder Springs, half a mile away in opposite directions.
"I like to walk with the girls --- we just enjoy running our mouths," Daniels said. "It's more sociable."
Howard Frumkin, a physician and chair of the Department of Environmental and Occupational Health at Emory's Rollins School of Public Health, said the connection between community design and health is intuitively appealing because it makes sense and affects a large number of people. He has written several journal articles on the subject with Jackson and Andrew Dannenberg, also a physician and scientist with the CDC.
The emerging movement is gaining traction in tandem with the idea of smart growth, compact development often built around public transportation and including a mix of uses, sidewalks and open space.
The American Journal of Public Health and the American Journal of Health Promotion each devoted their September issues to the impact of the built environment and health. The National Association of County and City Health Officials also made it the focus of its spring magazine.
Seeds for collaboration between planning and health departments are starting to germinate. The American Planning Association and the National Association of County and City Health Officials are meeting to encourage both sets of public employees to work together. In some areas of the country, officials from the public health department discuss projects with developers and planners when they're being proposed.
Others are pushing the idea of a health impact assessment, similar to an environmental impact assessment used to evaluate a development's effect on air and water quality. Dannenberg said it can inform county and city officials deciding on developments.
"A lot of public health department work has been fairly traditional. We try to clean up the water, inspect the restaurants, keep the septic systems and sewers running, develop vaccines," he said. "The [health impact assessment] idea is just catching on now. Public health needs to be at the table."
Pat Libbey, executive director of the health officials' association, said the connection between health and community design is clear. "You need a quart of milk. Does that obligate you to get in a car or walk three blocks?" If the answer is a car trip, residents are losing an opportunity for casual exercise, he contends.
The public health officials point to other benefits: > Less time spent commuting leaves more time for friends, children and community activities. > Fewer car trips mean less air pollution, which helps reduce asthma and respiratory problems. > With more time spent in the car, the probability of a crash becomes greater. > A lack of sidewalks also can lead to more pedestrian fatalities. > Pleasant environments such as parks can make people happier. Long-standing debate
Health officials stepped into debates about development, dating to the second half of the 19th century. They pushed for sewers. They saw connections between unsanitary and unventilated tenement buildings and disease. They recommended that polluting factories be built away from residential areas.
In a lecture this month to his public health students, Frumkin divided the influence into categories: pestilence and filth, industrial pollution, social pathology. And now sprawl.
Frumkin called landscape architect Frederick Law Olmsted a public health hero. Olmsted designed New York's Central Park and also served on the U.S. Sanitary Commission during the Civil War.
"He's a reminder that the way we design and build cities may have a lot to do with health," Frumkin told the class.
The idea is backed up by preliminary data from Frank's study, called SMARTRAQ, which shows a link between obesity and community design.
"Of the factors studied, land-use mix was the most effective tool available to decision-makers to reduce the likelihood of obesity," said Frank, who now teaches at the University of British Columbia and wrote a book about the subject. "The study confirms for the first time ever that increased time spent driving corresponds with a higher likelihood of being obese."
The health benefit of living in a mixed-use environment can be compared to the health benefit of being younger or wealthier, Frank said.
He assessed data collected from a subset of 320 metro Atlantans who wore monitors for two to three days. Preliminary results indicated that as homes per acre increase from two or fewer to eight or more, residents get 80 percent more moderate activity such as walking. Frank will present final results at a conference in Atlanta in early 2004.
Another study, funded by the Robert Wood Johnson Foundation, concluded that people who live in spread-out areas have a higher chance of obesity and high blood pressure than those who live in denser areas. The weight difference was as much as 6 pounds, when researchers compared Manhattan to a suburb of Cleveland.
The foundation, based in Princeton, N.J., is giving out about $80 million to fund and promote research on health and community design.
Still, Harvard's Glaeser has doubts about this kind of research. "The existing studies on sprawl and obesity are almost all terribly flawed," he said. "Most of them treat a correlation between sprawl and obesity as evidence that sprawl causes obesity."
In addition, he said, Americans are so car-oriented that will be hard to return to a pedestrian world.
"Unsurprisingly, the free market has come up with its own walking cities that are surely more popular than anything the smart-growth advocates are going to come up [with]," he said. "They are called shopping malls."
But Jackson of the CDC suggested more research could lead to new policies. He foresees community design campaigns similar to those against secondhand smoke and in favor of seat belts.
"I have been impressed that there is absolutely a tipping point when it comes to public opinion about health issues," he said. "At some point, things become more and more common sense and actual regulations change." --- Next week: How do other areas in the country assess developments through a health lens? What can Atlanta learn?
Copyright 2003 The Atlanta Journal-Constitution