July 2017





Healthy Communities Study findings on relationship between community policies and programs and childhood obesity

July 31, 2017, NCCOR

The Healthy Communities Study, funded by the National Institutes of Health in 2010, recently published findings in the American Journal of Preventive Medicine that show comprehensive community policies and programs (CPPs) addressing childhood obesity are associated with lower child adiposity.

The study aimed to understand how diet, physical activity, and body mass index (BMI) are related to aspects of CPPs. Researchers recruited 5,138 children and their families in 130 demographically diverse communities across the nation from 2013 to 2015. In each community, study staff assessed the number and characteristics of CPPs implemented over a 10-year span through interviews with key informants and a document review. Children’s height, weight, waist circumference, demographic data, and background characteristics on nutrition and physical activity behaviors were collected by trained staff. To compare the CPPs between communities, an intensity score was developed to measure the strength of CPPs based on behavior change strategy, duration, and reach.

Study results suggest an association between communities with CPPs that targeted more distinct physical activity and nutrition behaviors and lower BMI and smaller waist circumference in children in those communities. The authors concluded, “Healthy weight among children is influenced by conditions that make it easier and more rewarding to engage in multiple behaviors related to physical activity and healthy nutrition.” Comprehensive CPPs provide conditions in which children can easily access and feel motivated to engage in healthy and active behaviors.

The Healthy Communities Study contributes to NCCOR’s aim to identify and assess the relationships between CPPs and childhood obesity, diet, and physical activity to inform public health practice. NCCOR supported the Healthy Communities Study during its development and application review phase because of its emphasis on multilevel and/or multi-component approaches that will strengthen the capacity (e.g., knowledge, skills, tools) to implement evaluations and interventions. NCCOR continues to address questions related to possible drivers and contributors that may be influencing the reported declines in childhood obesity.

Read the Healthy Community Study findings: http://www.ajpmonline.org/article/S0749-3797(17)30263-5/fulltext

Original source: https://www.nccor.org/healthy-communities-study-findings-on-relationship-between-community-policies-and-programs-and-childhood-obesity/

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Publications & Tools

The Best Complete Streets Policies of 2016 report

As of the end of 2016, more than 1,000 jurisdictions in the United States have made formal commitments to streets that are safe and convenient for everyone—no matter their age, income, race, ethnicity, physical ability, or how they choose to travel—by passing a Complete Streets policy.

More communities passed these policies in 2016 than ever before. Communities adopted a total of 222 new Complete Streets policies that year. Nationwide, a total of 1,232 policies are now in place, in all 50 states, Puerto Rico, and the District of Columbia, including 33 state governments, 77 regional planning organizations, and 955 individual municipalities.

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The Challenge of Treating Obesity and Overweight: Proceedings of a Workshop—in Brief

The Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine held a workshop in Washington, DC, on April 6, 2017, titled, “The Challenge of Treating Obesity and Overweight: A Workshop.” The workshop discussions covered treatments for obesity, overweight, and severe obesity in adults and children; emerging treatment opportunities; the development of a workforce for obesity treatments; payment and policy consid- erations; and promising ways to move forward. This Proceedings of a Workshop–in Brief highlights key points made by workshop participants during the presentations and discussions. It is not intended to provide a comprehensive summary of information shared during the workshop.

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Food Buying Guide for Child Nutrition Programs interactive online tool

The interactive Food Buying Guide allows for easy searching, navigating, and displaying of content. In addition, users can compare yield information, create a favorite foods list, and access tools, such as the Recipe Analysis Workbook and the Product Formulation Statement Workbook.

Access the guide

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Childhood Obesity Research & News

One size does not fit all: The significance of design guidelines for small towns and rural communities

July 14, 2017, Alta Planning + Design

Until recently, photographs showcasing best practice bicycle and pedestrian design throughout the US had something missing. Design guidelines generally featured transit lanes, five story buildings, and wide sidewalks; all contemporary and innovative facilities were considered to be “urban” in nature. Missing from the conversation were smaller community and rural settings. Inspiration for engineers and planners in small towns was far and few between, with previous guidelines failing to reflect their reality.

By putting contemporary walking and bicycling facilities in a context that resonates with smaller communities, the Small Town and Rural Multimodal Networks guide offers a seat at the table for rural areas and smaller communities to showcase best practice design.

It addresses challenges specific to rural areas, recognizes how many rural roadways are operating today, and focuses on opportunities to make incremental improvements despite the geographic, fiscal, and other challenges that these smaller communities face.

The Road to Creating the Guide

The inception of this guide started back in 2010 when the United States Department of Transportation Policy Statement on Bicycle and Pedestrian Accommodation Regulations and Recommendations was released. This memo included a bold proclamation: “The United States Department of Transportation encourages transportation agencies to go beyond the minimum requirements, and proactively provide convenient, safe, and context-sensitive facilities that foster increased use by bicyclists and pedestrians of all ages and abilities…”. The Institute of International Engineers (ITE), National Association of City Transportation Officials (NACTO), and the Federal Highway Administration (FHWA) all responded to this call for design flexibility and multimodal facilities in earnest, but most resources were specifically focused on urban street design.

In 2015, Blue Cross and Blue Shield of Minnesota and FHWA funding came together for the development of a resource for active transportation design guidance in small town areas. Alta lead the production of the guide, determining how to fit existing and new guidelines into the rural context.

Significant Content

Not only does the guide translate existing national design guidance in a rural setting, it provides new, groundbreaking design guidance. For example, advisory shoulders create usable shoulders for bicyclists and pedestrians on a roadway that is otherwise too narrow to accommodate them. The shoulder is delineated by dashed line striping and optional contrasting pavement. Motorists may only enter the shoulder when no bicyclists or pedestrians are present and must overtake these users with caution due to potential oncoming traffic.

The Small Town and Rural Multimodal Networks guide provides the first US guidance for the use of advisory shoulders. As of early 2017, there are fewer than 20 installations in North America. Alta staff are working to develop a white paper to evaluate lessons learned from these existing advisory shoulder facilities.

Case Study Features

The guide also contains examples of peer communities and project implementation for the featured facility types throughout the guide. Case studies in the document include a project description, community context, key design elements, role in the network, and funding details.

By connecting communities to real stories, the guide passes on key lessons learned, including project triumphs and challenges.

On July 13, 2017, Alta hosted a webinar on the Small Town and Rural Multimodal Networks guide that featured two of the case studies from the guide.

Potential Impact of the Guide

Tim Gustafson, Senior Planner and head of the Chicago Alta office, is excited to see the guide help empower small town and rural communities. Gustafson was an editor for Best Design Practices for Walking and Bicycling in Michigan and Evaluating Pedestrian Safety Improvements for the Michigan Department of Transportation. He sees the new guide as a powerful resource to begin the discussion of what is possible in shaping roadway networks in small towns. “For some, it is my hope that they are better supported by the content in the Small Town and Rural Multimodal Networks guide to make decisions on their own local roadways, possibly with lower costs and more rewarding results knowing how much flexibility they have,” said Gustafson.

Technical Trainings

Alta staff have developed a variety of technical trainings and workshops, covering diverse street design subjects with a bicycle, pedestrian, and active transportation focus. Alta has led workshops on the Small Town and Rural Multimodal Networks guide across the country, including Washington, Oregon, Indiana, and New Hampshire.

We have developed training modules that guide professionals through network-scale and roadway-scale design exercises to teach the best and most appropriate application of facility types. Alta’s trainings range from full multi-day seminars to hour-long workshops and web-based curriculum.

Original source: https://medium.com/alta-planning-design/one-size-does-not-fit-all-d71ea92bbdc5

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Person-first, preventive approach needed to tackle obesity

July 12, 2017, American Medical Association

By Sara Berg

The numbers, so commonly cited, remain staggering. Obesity affects more than one in three American adults, according to the Centers for Disease Control and Prevention. It is also often associated with 236 comorbidities, such as diabetes, high blood pressure, heart disease and 13 different cancers. Yet physicians and other health professionals are too often hesitant to have open discussions about obesity with patients.

This uncharacteristic physician reticence was explored in a recent education session by Ethan Lazarus, MD, who reviewed current concepts in obesity medicine. Dr. Lazarus, the son of 2012–2013 AMA President Jeremy Lazarus, MD, is the secretary/treasurer of the Obesity Medicine Association (OMA). Practicing in suburban Denver, he specializes in helping individuals lose weight and live happier, healthier lives.

To overcome the stigma associated with obesity, Dr. Lazarus recommended opening the conversation and using person-first language (e.g. refer to a “patient with obesity,” instead of an “obese patient”). This can be performed if physicians begin to look at obesity like diabetes—there’s pre-obesity and obesity. It isn’t two separate diseases, but similar to diabetes, it allows physicians to provide measures to prevent obesity. By choosing the right approach, physicians can begin to address obesity with their patients without feeling uncomfortable.

Nearly half of people with obesity don’t even know they have it because health professionals are uncomfortable talking about it, Dr. Lazarus said during the education session at the 2017 AMA Annual Meeting. This is what is going on with obesity—half of the people with obesity don’t know if they have it or not. Of those that are diagnosed, 75 percent don’t receive a follow-up visit. They are diagnosed, know they have obesity, but they don’t receive any evidence-based treatment.

“The problem lies in the discussion,” said Dr. Lazarus. “Physicians are not comfortable speaking about obesity. It’s a different style of care than we would do with other diseases because there’s so much bias and stigma with weight.”

If physicians can overcome the idea that obesity is a fault-based disease, treatment can improve, he added

Obesity’s massive economic toll

A study by the Milken Institute found that direct medical cost of obesity is $427.8 billion, while total expense—including money spent on treating obesity-related conditions and lost work productivity—was $1.42 trillion. Treatment consumes 14.3 percent of health care spending and 320,000 deaths can be attributed to obesity annually. If physicians can help their patients drop 5 percent in weight, there can be over $2,137 cost savings per person.

“It’s hard to even imagine the magnitude of this problem, isn’t it? It’s such a huge problem,” said Dr. Lazarus. “This is nothing new. We know we should be screening patients for obesity.”

Many times physicians will see their patients and tell them to lose weight. But Dr. Lazarus suggested physicians go beyond instructing patients to lose weight—which he likened to instructing the patient to lower their blood pressure. Weight loss is more of an outcome than a treatment.

“Is anyone comfortable talking about diabetes?” asked Dr. Lazarus. “That’s an easy one to talk about. We recognize prediabetes and the goal is to not get diabetes. If the patient has diabetes we are going to monitor the patient.”

As with prediabetes, the goal in pre-obesity should be to prevent obesity. Providing education on eating and exercise; sleep; medication; and surgery—when needed—are all treatment options. It all starts with a conversation with the patient in the exam room, but it is important to use patient-sensitive language.

When it comes to drug therapies, it is important to understand when to stop and when to continue use. Dr. Lazarus recommended stopping a weight-loss drug treatment if it isn’t providing 5 percent weight loss after three months as that is not enough of a benefit to justify continued use.

Original source: https://wire.ama-assn.org/ama-news/person-first-preventive-approach-needed-tackle-obesity

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Understanding and improving arterial roads to support public health and transportation goals

July 12, 2017, American Journal of Public Health


Arterials are types of roads designed to carry high volumes of motorized traffic. They are an integral part of transportation systems worldwide and exposure to them is ubiquitous, especially in urban areas. Arterials provide access to diverse commercial and cultural resources, which can positively influence community health by supporting social cohesion as well as economic and cultural opportunities. They can negatively influence health via safety issues, noise, air pollution, and lack of economic development. The aims of public health and transportation partially overlap; efforts to improve arterials can meet goals of both professions.

Two trends in arterial design show promise. First, transportation professionals increasingly define the performance of arterials via metrics accounting for pedestrians, cyclists, transit riders, and nearby residents in addition to motor vehicle users. Second, applying traffic engineering and design can generate safety, air quality, and livability benefits, but we need evidence to support these interventions.

We describe the importance of arterials (including exposures, health behaviors, effects on equity, and resulting health outcomes) and make the case for public health collaborations with the transportation sector.

Motorized traffic is an essential part of modern life, but it also contributes to air and water pollution, fatal and nonfatal injuries, noise, and diminished quality of life related to traffic near residences. These are well-known public health problems in the United States and globally.1 In response, those in public health and urban planning have attempted to prioritize healthier forms of travel and land development to reduce automobile dependence. The public health profession has supported sustainable transportation policies and programs such as expanding public transit services, investing in transit-oriented land development, expanding opportunities for walking and cycling, implementing complete streets policies to improve infrastructure for all road users, and applying health impact assessments (HIAs) to transportation policies and projects.

However, it is equally important for the public health profession to address cars and other motorized traffic and the settings in which they operate. Doing so requires a complex way of thinking that allows for the idea that high traffic volumes can be managed in a manner that reduces negative effects on health and sustainability. One type of road—the arterial—warrants special attention from public health because its characteristics result in intense automobile use relative to other road types, leading to diverse influences on public health and health equity, and it is subject to ongoing redesign and reconstruction on an actionable time scale.

In this commentary, we define arterial roads and outline the exposures, health behaviors, and resulting outcomes associated with them. We emphasize arterials because, unlike interstates and freeways, they allow for mixed travel modes that present significant and unique challenges for pedestrians, cyclists, and transit riders. Arterial roads are also common sites for redevelopment and transportation upgrades, thus providing opportunities for public health and transportation professionals to work together. We discuss ways in which advanced street designs and technologies could improve arterials’ relationship to individual and community health and offer ideas for high-impact, multidisciplinary policy and design strategies to improve arterial roads for public health. Social equity is a critical theme relevant to arterials. Applying a health lens to arterials requires understanding practices in roadway planning and land development that influence inequities and resulting health disparities.

Original source: http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.303898

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Walking for transportation or leisure among U.S. women and men - National Health Interview Survey, 2005–2015

June 30, 2017, Centers of Disease Control and Prevention

Physical activity confers considerable health benefits, but only half of U.S. adults report participating in levels of aerobic physical activity consistent with guidelines. Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities identified walking as an important public health strategy to increase physical activity levels. A previous report showed that the self-reported prevalence of walking for transportation or leisure increased by 6 percentage points from 2005 to 2010, but it is unknown whether this increase has been sustained. CDC analyzed National Health Interview Survey (NHIS) data from 2005 (26,551 respondents), 2010 (23,313), and 2015 (28,877) to evaluate trends in the age-adjusted prevalence of self-reported walking among adults aged ≥18 years. The prevalence of walking increased steadily among women, from 57.3% in 2005, to 62.5% in 2010, and to 65.1% in 2015 (significant linear trend). Among men, a significant linear increase in reported walking was observed, from 54.3% in 2005, to 61.8% in 2010, and to 62.8% in 2015, although the increase stalled between 2010 and 2015 (significant linear and quadratic trends). Community design policies and practices that encourage pedestrian activity and programs tailored to the needs of specific population subgroups remain important strategies for promoting walking.

NHIS is a continuous in-person survey of U.S. households designed to be representative of the civilian, noninstitutionalized population. NHIS consists of a core questionnaire that collects basic health and demographic information for all family members in a sampled household and supplements that collect information about specialized topics. Questions specific to walking for leisure and transportation were asked of one adult aged ≥18 years per sampled household in the 2005, 2010, and 2015 Cancer Control Supplements. Sample adult response rates were 69.0% (2005), 60.8% (2010), and 55.2% (2015).

Walking was defined as engaging in at least one 10-minute period of transportation or leisure walking in the past 7 days at the time of survey. To assess transportation walking, respondents in all 3 years were asked, “During the past 7 days, did you walk to get someplace that took you at least 10 minutes?” To assess leisure-time walking, respondents in 2005 were asked, “During the past 7 days, did you walk for at least 10 minutes at a time [for fun, relaxation, exercise, or to walk the dog]?” and in 2010 and 2015, “During the past 7 days, did you walk for at least 10 minutes [for fun, relaxation, exercise, or to walk the dog]?”

Demographic characteristics (sex, age, race/ethnicity, and education level) and health-related characteristics (height, weight, walking assistance status, and physical activity) were also assessed. Meeting the aerobic physical activity guideline of at least 150 minutes of moderate-intensity equivalent aerobic activity per week was assessed using responses on the usual frequency and duration of light- to moderate-intensity and vigorous-intensity leisure-time physical activity.

From the initial total sample of 92,257 (31,428 [2005]; 27,157 [2010]; and 33,672 [2015]), 13,516 (15%) persons were excluded, including 2,280 who were unable to walk and 11,236 for whom data were missing for walking (6,044), physical activity (1,054), health-related characteristics (3,708), or demographic characteristics (430). Thus, the final analytic sample consisted of 78,741 respondents (26,551 [2005]; 23,313 [2010]; and 28,877 [2015]).

The proportion (with 95% confidence intervals) of adults who reported walking each year was calculated. Linear and quadratic trends in walking prevalence from 2005 to 2015 were tested using logistic regression, controlling for age group. For three time points, a temporal change that includes significant linear and quadratic trend terms indicates an overall increase or decrease over time as well as a deviation from linearity. For example, if the linear trend is positive and quadratic trend is negative, this indicates an increase from 2005 to 2015 with a stalling or leveling off between 2010 and 2015. Because significant interactions between sex and trend terms were observed, sex-specific results are presented. Subgroup analyses were conducted by age group, race/ethnicity, education level, U.S. Census region, body mass index category, walking assistance status, and meeting the aerobic physical activity guideline, and pairwise differences between subgroups and across years were tested using adjusted Wald tests. Statistically significant (p<0.05) results are reported. All analyses accounted for the complex survey design. Reported estimates are weighted and age-standardized to the 2000 U.S. standard population.

In 2015, women were significantly more likely to report walking (65.1%) than were men (62.8%) (Figure). Among women in 2015, the lowest reported prevalence of walking was among those aged ≥65 years, non-Hispanic blacks (blacks), and residents of the South, compared with their respective counterparts (Table 1). Among men in 2015, the lowest prevalence of walking was among blacks and Hispanics and the highest prevalence was among men in the West, compared with their respective counterparts (Table 2). Among males, there were no significant age group differences in walking prevalence. The prevalence of walking was lower among men and women with a high school education or less, who had obesity, who needed walking assistance, or who did not meet aerobic physical activity guidelines than among their respective counterparts.

Among women, the prevalence of walking demonstrated a significant linear increase from 2005 to 2015, with no significant quadratic trend. This trend remained when stratified by selected characteristics, with two exceptions: both linear and quadratic trends were significant among women who were overweight or lived in the Midwest. The increase in walking prevalence among women between 2010 and 2015 was significant overall (2.7 percentage points) and among select strata (age 45–64 years, age ≥65 years, non-Hispanic whites, college graduates, residents of the Northeast and South regions, those who were underweight or normal weight, those with obesity, and those not needing walking assistance).

Among men, a significant positive linear and negative quadratic trend in reported walking from 2005 to 2015 was observed overall and for most subgroups, with the increase stalling from 2010 to 2015. The change in walking prevalence among men from 2010 to 2015 was not significant overall or when estimates were stratified by selected characteristics, with one exception: among men aged ≥65 years, the prevalence of walking increased by 3.8 percentage points from 2010 to 2015.


The prevalence of reported walking for transportation or leisure among men and women increased between 2005 and 2015; however, for men, the increase stalled between 2010 and 2015. This trend among males is similar to trends for leisure time physical activity, with the reported prevalence of meeting physical activity guidelines increasing steadily from 2008 to 2012 and stalling between 2012 and 2015. However, even given this increase, nearly one third of women and men report that they did not walk for at least 10 minutes in the past week.

Walking is an easy way for most adults to incorporate more physical activity into their daily routines. Women are less likely than men to achieve physical activity levels sufficient to meet guidelines. However, this study found that walking has become increasingly common among women since 2005, representing a potential opportunity for addressing the gender difference in overall physical activity. Efforts to sustain the observed increase in the percentage of adults who walk could contribute to more adults meeting guidelines, potentially reducing the burden of chronic diseases and premature death associated with low levels of physical activity. For example, communities can create additional opportunities for walking by implementing walking programs tailored to the interests and abilities of specific subgroups of the population. In addition, policies and practices that improve the safety of communities and promote walkable design can help make walking a convenient option for almost all persons.

For both women and men, walking was least prevalent among blacks and persons with lower educational attainment, groups that have been shown to report lower levels of physical activity compared to their counterparts. In some cases, differences in walking appear to be widening over time. For example, among men, walking increased at a steady rate among college graduates from 2005 to 2015 (significant linear trend only), but stalled between 2010 and 2015 among those who did not graduate from high school (significant linear and quadratic trends). Low socioeconomic status (SES) and minority neighborhoods are often perceived as less attractive and less safe because of traffic or crime when compared with higher SES and majority white neighborhoods (9). Efforts to overcome such environmental barriers to walking in these communities, like policies and practices that improve the safety and quality of community supports for physical activity (e.g., trails and sidewalks), might help to reduce the observed disparities in walking.

The findings in this report are subject to at least four limitations. First, this analysis relies on self-reported data, and social desirability bias might result in overestimates of walking. Second, the wording of the question about leisure walking changed slightly between 2005 and 2010; to improve comparability between years, participants in all years who reported that a typical walking period lasted <10 minutes (1,076 respondents) were categorized as nonwalkers. Third, survey response rates could contribute to response bias if nonresponders differed systematically from responders, although weighting procedures should reduce the impact of survey nonresponse. Finally, approximately 6% of respondents were missing walking data each year; the application of sample weights would not be expected to mitigate any potential bias associated with missing data.

The reported prevalence of transportation or leisure walking among women and men increased from 2005 to 2015, although among men, the increase has stalled in recent years. By implementing community and street scale design strategies that encourage pedestrian activity and by supporting walking programs where persons spend their time, communities can improve walkability and make walking a safer and easier option for increasing physical activity.

Original source: https://www.cdc.gov/mmwr/volumes/66/wr/mm6625a1.htm?s_cid=mm6625a1_w

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