Mark Fenton; [e-mail]

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Mark Fenton mark.fenton_at_verizon.net

• Fighting the Epidemic No One is Talking About
• -
• Reversing the Tide Creating a Healthier Maine
• Portland, ME
• May 2007

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Topics for today

• Restating the problem and a brief rant about the
  epidemic.
• A question of priorities, and five
  recommendations.
• The stickiness problem and environmental change.
• The three P solution.
• Why it really matters.

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US Obesity EpidemicOgden et. al. (JAMA 288,
14 Oct. 2002)
Americas looming chronic disease apocalypse . .
.
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USA TodayMar. 2005
ENVIRONMENT Oil drilling in Alaska Natl
Wildlife Refuge.
ECONOMY (inside) GM profits plummet . . .
HEALTH Obesity threatens life expectancy.
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Diabetes Prevention Program(DPP New.Eng.J.Med.,
April 2002)

• Compared three treatments for nationwide cohort
  (3,000) at risk for developing diabetes
  (elevated fasting glucose).
• Control Standard exercise and nutrition
  counseling placebo.
• Standard plus drug treatment Metformin
• Intensive lifestyle change Nutritional training,
  150 min./week physical activity.

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Diabetes Risk Reduction(Diabetes Prevention
Program NEJM, April 2002)
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My RantChange the conversation. Its not just
an obesity epidemic. Its an epidemic of physical
inactivity and poor nutrition.
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Rank the priority of these five activities

• America on the Move national meeting.
• Local planning board meeting re trail.
• Belmont Health Fair lead walks, etc.
• Address Governors task force on the MA Highway
  Design Manual.
• Nordic Walking (w/poles) fitness DVD.

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Health Fair
But how much, and what activity to recommend to
average people?
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Surgeon Generals Report on Physical Activity
Health, 1996

• 30 minutes of moderate physical activity.
• Most (all) days of the week.
• Can be broken up.
• Reduced risk for CVD, diabetes, osteoporosis,
  obesity, dementia in old age, clinical
  depression, a growing list of cancers.

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But, Health Fair is 5 because

• Only reaches those who show up!
• And only a fraction of those will actually use
  the information.

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Recommendation 1 Think about scale. Ask the
simple question for how many people will this
actually change behavior?
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Nordic Walking benefits

• 20 - 40 boost in energy expenditure.
• Increased upper body workout (arms, chest
  shoulders, back, abs).
• Improved balance reduced loads on feet, legs.

www.nordicwalker.com
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BUT Nordic Walking?Another fitness fad? What
about the dork factor? Or the stickiness
problem?
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My admittedly unique perspective . . .
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Exercise ParticipationEffect of Short Bouts,
Home Treadmills(Jakicic et.al., JAMA 282, 16)
?
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Exercise ParticipationEffect of Short Bouts,
Home Treadmills(Jakicic et.al., JAMA 282, 16)
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Self-help vs. CommercialWeight Loss Programs
(Heshka et.al., JAMA 289, 14 April 9, 2003)
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Physical Activity in the US (MMWR 50 (09)
166-9 Mar. 9, 2001)
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Recommendation 2 Go for breadthnot just
exercise for the actively inclined. We need
increases in routine, daily physical activity for
everyone.
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America on the Move Pedometer based, targets
2,000 step/day increase. The focus is on routine
lifestyle activity.
www.americaonthemove.orgwww.letsgo.org
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How has advising people to take the stairs . .
.worked?
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Energy ExpenditureLifestyle vs. Structured
Activity(Dunn et.al., JAMA 281, 4)
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An approach to increasing physical activity . .
.

• P.A.P.P.I. (?)

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Physical Activity Promotion through Predator
Introduction
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Social Ecology ModelDeterminants of behavior
changeSallis, Owen, Physical Activity and
Behavioral Medicine.

• Individual (readiness, efficacy)
• Interpersonal (family, friends)
• Institutional (school, work, HMO)
• Community (networks, local govt)
• Public Policy (transport, land use)

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Socio-ecological success tobacco

• Individual education, medication
• Interpersonal 2nd hand smoke, kids
• Institutional work place bans
• Community smoke free policies
• Public Policy taxes, enforcement, advertising
  bans, SGs warning label.

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vs.
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The ideal trip decision hierarchy
Nearly 25 of trips are less than or equal
to one mile. (1995, NPTS)

Walk
Bike
Transit
Drive
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Recommendation 3 We have to make physical
activity the easier choice - actually safer, more
convenient, and more fun than being sedentary.
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Planning BoardDirectly impacts local
environmental factors.
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The Toxic Environment?
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US19 Pinellas Co.
The Toxic Environment here?
You bet!
Cycling along Rt. 1
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So, what seems to matter?

• Destinations within walk bike distance?
• Sidewalks, trails, bike lanes, crossings?
• Inviting settings for bikes pedestrians?
• Is it safe?

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Land use.
Schools, anchors in town.
Smaller lot sizes . . .
. . . and shared open space.
Mixed use, multi-family.
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Network.

• Presence of sidewalks, paths.
• Shorter blocks, more intersections.
• Access to trail, park, greenway, transit.

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Bicycle network options
Denver, CO
Sacramento, CA
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Site design
Where would you prefer to shop on foot?
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Site design.

• Pedestrian friendly architecture is near the
  street, not set back.
• Trees, benches, water, aesthetics, human scale.
• Details bike parking, greenery, open space . . .

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Safety.

• Engineering can dramatically improve safety.
• Increasing ped and bike trips decreases overall
  accident fatality rates.

(Jacobsen et.al., Transportation Safety)
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The preferred residential street?
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Suburbanization of AmericaUS population shift,
1950-1996(after Bowling Alone, R. Putnam, 2000)
But what about rural areas . . . ?

• Suburbia is steadily consuming the landscape . . .

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2. Rural areas are where we can affect the shape
of development before its done!
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Recommendation 4The environment of the whole
system matters, so work on improving it. Start by
getting people realizing what works and what
doesnt.
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• Highway Design Manual
• Affects the built environment for years to come.

X
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The Story of 4

• 4,000

Approximate number of annual pedestrian deaths in
America.
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• 40,000

Approximate total annual deaths in motor vehicle
crashes.
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• 400,000

Approximate annual deaths due to sedentary living
and poor nutrition. Rounded up from corrected
365,000. Mokdad, A.H., et al. 2004. Actual causes
of death in the US. JAMA 291 1238-45.
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• 40,000,000,000

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• 40,000,000,000

Approximate direct annual medical expenditures
due to inactivity poor nutrition, borne by
taxpayers. www.cdc.gov/nccdphp/dnpa/ (Obesity
Research, Finkelstein et.al., Jan, 04)
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So my choices

• Highway Design Manual, Governors Task Force.
• Local planning board meeting.
• America on the Move national meeting.
• Nordic Walking (w/poles) fitness video.
• Dont bother Community Health Fair.

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A QUIZ How best to invest to reduce cost
of employee health care?

• Build a fitness center/gym.
• Launch active commute program (e.g., covered
  bike parking, lockers, showers).
• Host a health fair speaker series.
• Build a trail around/near worksite.
• 16 week employee walking program.

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• Economic
• Residents shop locally more stable tax base.
• Healthy employees, low turnover, happy
  employers.
• Healthy housing values
• (NAHB NAR surveys).

Other benefits?

• Environmental
• Reduced traffic air, water, noise pollution.

• Safety
• Kids, elderly mobility.
• Crime deterrent.

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Recommendation 5You must use all three Ps!

• Programs Build awareness, support, skills,
  plans.
• Projects Improve the built environment for
  walking, cycling.
• Policies Rewrite the rules so the changes stick!

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Programs Promotion
Safe Routes to School www.saferoutesinfo.org
Walking school busses, bicycle trains, safety
education.
Active- commute incentives E.g., Bike to work
day, tax free transit pass, health benefit
discount.

• Worksite activity programs.
• E.g. America on the Move
• www.americaonthemove.org

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Start with one-shot events, but look toward
long-term impacts.

• Monthly, weekly, daily farmers market, walking
  event.
• Walk, bike to work efforts financial rewards,
  vacation?
• Street fair, walk, concert, (close a street).

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Projects
Bike lanes, narrowing, traffic calming, multi-use
trails.
www.completestreets.org
Bike parking, lockers, showers walking paths,
countdown timers.

• Road paint, cones, curbs, plantings, . . .

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Policies
School siting, district lines, bus policies.
DPW snow removal, complete streets.
Zoning Mixed use, accessory dwellings, open
space conservation.
www.completestreets.org
Site standards Setbacks, parking, access.
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This means a whole new batch of partnerssome
familiar, some not

• Schools
• Planning Zoning
• Parks, Recreation
• Historical Society
• Public Health Safety
• Chamber of Commerce
• Economic Development
• Neighborhood Associations
• Environment, Conservation

Policy information www.lgc.org www.vtpi.org
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This guy is a new model of success!
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Current related measures

• Needed Measures
• Sufficiently active
• Recreation
• Occupation
• Transportation
• Policy Measures
• Zoning codes
• Subdivision regulations
• Environmental measures
• Land use mix
• Bike/ped network
• Complete Streets

• Physical Environment
• Farm acreage
• Woodland acreage
• Public Park acreage

• Public Health
• Overweight/Obesity
• Heart Disease
• Diabetes
• Public Park acreage

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Collier County active community summit.

• Interdisciplinary sponsors participants.
• Included walk audit good media hook.
• Created DVD about event active living movement.

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The discovery of Marks Hawaii vacation
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An island at risk . . .
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Kaloko-Honokohau Natl Historical Park