Persuasive research paper

Physical Activity and Food Environments: Solutions to the Obesity Epidemic Author(s): James F. Sallis and Karen Glanz Reviewed work(s): Source: The Milbank Quarterly, Vol. 87, No. 1 (Mar., 2009), pp. 123-154 Published by: Wiley-Blackwell on behalf of Milbank Memorial Fund Stable URL: http://www.jstor.org/stable/25474362 . Accessed: 22/11/2012 03:47

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Physical Activity and Food Environments:

Solutions to the Obesity Epidemic

JAMES F. SALLIS and KAREN GLANZ

San Diego State University; Emory University

Context: Environmental, policy, and societal changes are important contribu

tors to the rapid rise in obesity over the past few decades, and there has been

substantial progress toward identifying environmental and policy factors related

to eating and physical activity that can point toward solutions. This article is

a status report on research on physical activity and food environments, and it

suggests how these findings can be used to improve diet and physical activity and to control or reduce obesity.

Methods: This article summarizes and synthesizes recent reviews and provides

examples of representative studies. It also describes ongoing innovative in

terventions and policy change efforts that were identified through conference

presentations, media coverage, and websites.

Findings: Numerous cross-sectional studies have consistently demonstrated

that some attributes of built and food environments are associated with physi cal activity, healthful eating, and obesity. Residents of walkable neighborhoods who have good access to recreation facilities are more likely to be physically active and less likely to be overweight or obese. Residents of communities with

ready access to healthy foods also tend to have more healthful diets. Disparities in environments and policies that disadvantage low-income communities and

racial minorities have been documented as well. Evidence from multilevel stud

ies, prospective research, and quasi-experimental evaluations of environmental

changes are just beginning to emerge.

Conclusions: Environment, policy, and multilevel strategies for improving

diet, physical activity, and obesity control are recommended based on a rapidly

Address correspondence to: James E Sallis, Active Living Research, 3900 Fifth

Avenue, Suite 310, San Diego, CA 92103 (email: sallis@mail.sdsu.edu).

The Milbank Quarterly, Vol. 87, No. 1, 2009 (pp. 123-154)

? 2009 Milbank Memorial Fund. Published by Wiley Periodicals Inc.

123

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124 J'P- Sallis and K. Glanz

growing body of research and the collective wisdom of leading expert orga

nizations. A public health imperative to identify and implement solutions to

the obesity epidemic warrants the use of the most promising strategies while

continuing to build the evidence base.

Keywords: Built environment, policy, nutrition, health behavior, ecological

models.

Environmental Change as an Essential Part

of the Solution to Obesity

EXPANDING PORTION SIZES, COMPUTER GAMES, HIGH-FRUCTOSE

corn sweeteners, automobile-dependent community designs, food

advertising everywhere, transportation investments to support

only automobile travel, more and cheaper foods high in fat and sugar, school facilities off limits to the community, soft drinks in schools, Internet entertainment options, and ubiquitous fast food. Changes in

these and other factors have been blamed for the obesity epidemic in

the United States and across the world. Although it is unlikely that

biologically based preferences for sweet and fat have changed, there now

is a greater variety of these preferred foods; there are more places to get

them; they are advertised more widely; and they

are cheaper and come

in larger sizes. Our ancestors probably obtained most of their physical

activity during work, household chores, and transportation, but today these requirements for

movement have been greatly reduced owing to

automation and computers at work, labor-saving devices at home, and

building and transportation practices that require driving for most trips. The consensus among public health experts is that changes in genes,

biology, and psychology at the individual level cannot explain the rapid rise in obesity,

so the explanation must lie in broader environmental,

policy, and societal changes (Hill and Peters 1998; Koplan and Dietz

2000; Koplan, Liverman, and Kraak 2004; Kumanyika et al. 2000; WHO 2004).

Even though attempts to identify those environmental and policy

changes responsible for the obesity epidemic have not produced any clear answers, there are, nonetheless, numerous changes that, by altering

patterns of eating and physical activity, may have contributed to the

epidemic (Jebb and Moore 1999; Popkin 2007; Sturm 2005). Although

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Solutions to the Obesity Epidemic 12 5

it may not be possible to establish the exact degree to which various en

vironments and policies contribute to the epidemic, substantial research

progress has been made to identify environmental and policy factors that can point us toward solutions. This article is

a status report on research

on physical activity and food environments, and it suggests how these

findings can be used to guide policy actions to control obesity.

Physical activity environments are places where people can be physi

cally active. Of most interest are places that can be designed to support

daily activities, such as

parks, sidewalks, trails, schools, workplaces, play

grounds, child care settings, and private recreation facilities. Common

settings for sedentary behavior include homes (filled with electronic en

tertainment and labor-saving devices), workplaces, sports venues (where

the vast majority sits and watches others move around), schools, and

roadways built to optimize travel by car. It thus is essential to consider

"information environments" that directly or

indirectly encourage un

healthy eating behaviors and sedentary habits through numerous media

that usually do not encourage healthy behaviors. Sedentary behaviors are those that involve sitting

or minimal energy expenditure. Television

viewing, computer use, computer games, and driving/riding in cars are

some of the largest contributors.

Several levels of the food environment have been identified. The com

munity environment refers to the places where food can be obtained, like

grocery stores, convenience stores, specialty stores, restaurants, and farm

ers' markets that are generally open to the public. Microenvironments

accessible to limited groups include homes, workplace and school cafe

terias, and churches. The consumer environment describes what a person

is exposed to inside the food sources, especially in regard to the avail

ability of different types of foods, promotions, and prices (Glanz et al.

2005). Policies are the primary mechanism for making environmental

changes and include formal and informal rules, laws, and regulations. Both government and industry policies control food environments. Poli cies pertaining to parks and recreation, education, transportation, and

planning departments in governments at multiple levels have direct

responsibility for physical activity environments. School and employer policies dictate the resources, incentives, and/or deterrents to healthy

eating and active lifestyles in organizations where children and adults

spend most of their days. Finally, at a very local level, family policies control food and physical activity environments in the home.

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126 J.F. Sallis and K. Glanz

The thinking and research on eating, physical activity, sedentary behaviors, and obesity have been guided until recently by biological and

psychological models and theories focusing on individuals, families, and small social groups such as friends and coworkers. The rapidity of the rise of the obesity epidemic and the discovery that most interventions to help individuals change their eating and physical activity behaviors have only weak and short-lived effects (Kumanyika et al. 2000; Marcus et al. 2000) reveal the limitations of the dominant individually focused models of behavior.

Ecological models are characterized by their specification of multi

ple levels of influence on behaviors, including individual (biological, psychological), social and cultural, organizational (schools, workplaces, health care), community (including physical activity and food environ

ments), and policy levels. Although ecological models have been used for decades in public health and the behavioral sciences, their influence has been modest. More recently, improved measurement methods, advances

in multilevel analyses, the development of models specific to each target behavior, and dedicated funding for environmental and policy research

have enhanced the impact of ecological models (Sallis, Owen, and Fisher

2008). A central lesson of ecological models is that because behavior is in

fluenced at multiple levels, the most effective interventions also should

operate at multiple levels. Diet and physical activity interventions that

build knowledge, motivation, and behavior change skills in individuals

without changing the environments in which they live are unlikely to

be effective. Similarly, merely changing the physical activity or the food

environment may not be sufficient for a substantial change in behavior.

Based on ecological models we expect the most effective interventions

to operate on multiple levels to create an environment that makes it easy

to make the healthy choice (e.g., renovate the park, stock skim milk

in stores), enhance social norms and social support (e.g., with a media

campaign), educate and motivate individuals to take advantage of the

opportunities for healthy behaviors, and use policy to reduce prices for

healthy foods or to provide activity programs in parks. The benefits

of including environmental and policy components in a comprehensive intervention are their ability to affect every person living in the environ

ment or jurisdiction affected by that policy. Effects should last as long as

the person is in the environment or the policy is in effect (Sallis, Owen, and Fisher 2008).

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Solutions to the Obesity Epidemic 127

This article draws on reviews and recent studies to demonstrate the state of knowledge regarding environmental and policy correlates of eat

ing and physical activity, especially equity of access to health-promoting environments. We then use this evidence to recommend environmental

and policy changes that are likely to improve eating, physical activity, and obesity.

Lessons from Research on Physical Activity Environments

One principle of ecological models is that they need to be tailored to

specific behaviors. Accordingly, environmental and policy influences are expected to have particularly behavior-specific effects (Sallis, Owen, and Fisher 2008). One recent ecological model proposes interventions for each of four domains of physical activity: occupation, recreation,

transportation, and household (Sallis et al. 2006). The following section discusses research findings organized by domains of physical activity and specific settings. Because the number of research publications in

this field has increased dramatically since 2000 (Sallis et al. 2009), we

summarize recent review articles when available and provide examples

of representative studies.

Environments to Support Active Recreation

People can find recreational physical activities in public parks and trails, on sidewalks or streets, at private facilities like health clubs, and in their homes. There is substantial evidence that people who live closer

to a variety of recreation facilities are more physically active overall.

Of the ten review articles that Bauman and Bull (2007) summarized, nine recognized the value to adults of proximity to recreation facilities. Davidson and Lawson (2006) reviewed the literature for children and concluded that living

near parks, playgrounds, and recreation areas was

consistently related to children's total physical activity. The research

finding that people were more active in some areas of parks (e.g., basket

ball and racquet courts) than in other areas (e.g., baseball fields, picnic areas) (Floyd et al. 2008) can guide the design of recreation facilities.

The aesthetics of physical activity settings is consistently related to adult activity, with five of six reviews that covered aesthetics supporting

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128 J.F. Sallis and K. Glanz

this conclusion (Bauman and Bull 2007). In addition, features like trees, attractive buildings, and water views may make recreational physical

activity more pleasant. Sidewalks can be used for walking for both

recreation and transport purposes, and nearly all the reviews concluded

that the availability of sidewalks was positively associated with physical

activity and walking (Bauman and Bull 2007) for adults and children

(Sallis and Kerr 2006).

Environments to Support Active Transportation

Walking from place to place was surely a major source of physical ac

tivity in preindustrial times. Currently, in many European countries, 30 percent or more of trips are made by walking and cycling, a figure that shrinks to less than 10 percent in the United States (Pucher and

Dijkstra 2003). To reduce air pollution and traffic congestion, trans

portation planners studied how the design of communities is related to

choices of travel modes, and they consequently developed the concept of "walkability," referring to people's ability to walk (or cycle) to des

tinations. The key concepts are proximity of destinations to residences

and street networks that create a relatively direct route. For thousands of

years, towns and cities were built according to these principles, because

most people walked to where they needed to go. But now, with the

mass adoption of automobiles as the primary mode of transportation,

land use and transportation practices have changed to ensure that most

trips must be taken by car. Therefore, instead of the mixed-use zoning

required for walkability, zoning has increasingly separated uses, and as

a result, shopping areas and employment

centers are far from where

people live (Schilling and Linton 2005). And instead of streets built on

a grid pattern providing direct routes, suburban subdivisions contain

disconnected and winding streets, making trips by the street network

much longer than straight-line distances. Likewise, roads are designed to facilitate high-speed travel by cars, often with little consideration of

the needs of pedestrians or cyclists.

Dozens of studies show that adults who live in walkable neighbor hoods walk and cycle more for transportation and are more physically active than are those who live in suburbs designed to be dependent on

automobiles. In Bauman and Bull's (2007) review of reviews, four of

four reviews found that the walkability of a neighborhood or region was

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Solutions to the Obesity Epidemic 129

positively related to physical activity, and the components of mixed use

(five of six reviews), connectivity (three of three reviews), and residential

density (six of six reviews) also were supported as physical activity cor

relates. A smaller number of recent studies showed similar associations

of walkability and physical activity among youth, including active com

muting to school, and among older adults (Sallis and Kerr 2006). As an

example, Frank and colleagues (2005) used a walkability index based on

Geographic Information Systems and measured physical activity objec

tively with accelerometers. They found that 37 percent of adults in the

highest-walkability neighborhoods met the recommendation of physical

activity for thirty minutes per day, compared with 18 percent of those

in the lowest-walkability neighborhoods. Based on a systematic review,

an expert panel from the Transportation

Research Board and Institute of Medicine (2005) concluded that built

environment factors were indeed related to physical activity. The Centers

for Disease Control and Prevention's (CDC) Task Force for Community Preventive Services determined that land-use changes are

an evidence

based intervention for promoting physical activity (Heath et al. 2006). Characteristics of transportation systems and practices have been

linked with the physical activities of youths and adults. The findings for children and adolescents include parental concerns about traffic

as a

strong correlate of children's active transport to school (Kerr et al. 2006), and having to cross busy streets as a barrier to children's physical activity (Davidson and Lawson 2006). Among adults, people drive more when

they live in low-walkable suburbs. Driving itself is an independent risk

factor for obesity (Frank, Andresen, and Schmid 2004; Lopez-Zetina, Lee, and Friis 2006), whereas users of public transit are more likely to meet physical activity guidelines (Besser and Dannenberg 2005).

Physical Activity Environments and Obesity

According to a recent review by Papas and colleagues (2007), about

twenty studies have examined associations between built environment

attributes and indicators of weight status. Sixteen of those studies ex

amined built environment variables related to recreation facilities or

community design, and almost all of them found significant associa tions with obesity. For example, Frank and colleagues (2004) discovered that neighborhood walkability was related to the risk of obesity in adults

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130 J.F. Sallis and K. Glanz

and that physical activity partially explained this association. In a na

tional study of adolescents, Gordon-Larsen et al. (2006) demonstrated

that the proximity of recreation facilities was correlated with the risk

of overweight and obesity. Thus, a substantial database associates liv

ing in areas lacking recreation facilities and not supporting walking for

transportation as a risk factor for obesity.

Designing Schools to Support Active Students. Because schools are central

to children's lives, it is important to consider how they can be built

to support physical activity. Several studies illustrate the connection.

Schools with a richer activity environment, including basketball hoops and soccer goals, combined with adult supervision or equipment, had

significantly more students who chose to be active after lunch or after

school (Sallis et al. 2001). A controlled study in the United Kingdom found that simply marking elementary school playgrounds with designs that stimulated active games was associated with a 20 percent long term improvement in physical activity (Ridgers et al. 2007). Although one study associated having large school grounds with physical activity

(Cradock et al. 2007), there is concern that requirements for large school

yards may force new schools to be placed on the periphery of commu

nities, which ironically could prevent most students from walking or

cycling there.

Designing Buildings to Support Physical Activity. Although people

spend most of their lives in buildings, there is surprisingly little study of

building design and physical activity (Zimring et al. 2005). Numerous

studies have found that signs promoting stair use (i.e., an intervention

in the information environment) had modest effects at low cost (Kahn

et al. 2002). A few studies have shown that the attractiveness of stairs

(Kerr et al. 2004) and more convenient access to stairs than to elevators

(Nicoll 2007) were associated with greater stair use. However, where

buildings are built may affect physical activity more than how they are

designed. As described earlier, separate-use zoning forces most workers

to drive to their workplaces because they are too far from their homes to

walk or cycle.

Disparities in Access to Activity-Friendly Environments. Because of the

dramatic disparities among race, ethnicity, and socioeconomic status

in regard to obesity (Ogden et al. 2006), it is important to con

sider to what extent disparities in access to activity-friendly environ

ments might explain these findings. Substantial evidence shows that

access to parks and other recreation facilities is lower in low-income,

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Solutions to the Obesity Epidemic 131

low-education, and minority communities, at least in the United States.

Two national studies documented this trend (Gordon-Larsen et al. 2006; Powell et al. 2006), with one study finding less access to every category of

recreation facility in low-education communities (Gordon-Larsen et al.

2006). A study in Austin, Texas, showed that low-income, majority Latino neighborhoods were more walkable than high-income, mostly

non-Hispanic white neighborhoods in the suburbs. The low-income

Latino neighborhoods, however, had poorer safety ratings, maintenance,

and aesthetics that could interfere with residents' ability to benefit from

the walkable design (Zhu and Lee 2008). Maclntyre (2007) concluded that not all studies found disparities in access to parks and other physi cal activity environments. Although quality of activity facilities may be

more important than presence, it has seldom been studied.

A disturbing early finding was that walkability was related to physical

activity (Frank et al. 2005) and obesity (Frank, Andresen, and Schmid

2004) among non-Hispanic whites, but not among African Americans.

Perhaps the less favorable safety and aesthetic features of the African

American neighborhoods could explain the lack of walkability effects, as suggested by Zhu and Lee's (2008) results, but further studies are

needed. A contrasting result is that access to nearby recreational facili

ties was strongly related to physical activity among African Americans

and Latinos, but not among non-Hispanic whites (Diez Roux et al.

2007). Currently there are more questions than answers about the role

of physical activity environments in explaining racial, ethnic, and so

cioeconomic disparities in physical activity and obesity.

Evaluating Environmental Changes to Promote

Physical Activity Most of the studies of physical activity environments have been

cross-sectional, leading to criticism about whether apparent effects of

environments can be explained by active people tending to choose

activity-friendly communities (Handy, Cao, and Mokhtarian 2006). Be cause it is not feasible to randomly assign people to neighborhoods, other

study designs must be used to determine whether the environment is a true cause of behavior. A study of people who changed their residence found that activity levels tended to increase among those who moved to

more walkable neighborhoods and that activity decreased among those

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132 J.F. Sallis and K. Glanz

who moved to less walkable areas (Handy, Cao, and Mokhtarian 2008). A study of low-income women who moved partially supported a con

clusion that changing environments can stimulate expected changes in

physical activity (Wells and Yang 2008), even though a study of adoles

cents showed that moving was not related to changes in weight status

(Ewing, Brownson, and Berrigan 2006). A more powerful approach is

to use quasi-experimental designs, of

ten called "natural experiments," to evaluate environmental changes

as

opportunities arise. A review of United Kingdom studies found that

opening new sections of cycling trails led to long-term increases in cy

cling, especially when they were located in highly populated areas (NICE

Public Health Collaborating Centre 2006). Evaluations of new trails in

the United States have had mixed effects, with some finding increased

physical activity (Gordon, Zizzi, and Pauline 2004) and others finding no impact (Evenson, Herring, and Huston 2005). These studies indicate

that environmental modifications can change physical activity, but it is

not clear which environmental changes are most effective.

Limitations of Available Research

The cross-sectional design of most physical activity environment studies

is often cited as their major methodological limitation (Transportation Research Board and Institute of Medicine 2005), so recent prospective and quasi-experimental evaluations

of environmental changes are re

garded as important advances. These more rigorous designs should also

be applied to other environmental attributes and to more diverse popula

tions, including subgroups at high risk of obesity. Other areas for future

research are examining more detailed environmental measures and es

tablishing dose-response relationships so the results can be more directly

applied by designers and policymakers. Although sedentary behaviors

are risk factors for obesity, few studies have examined the environmental

correlates of these behaviors.

Because studies use a diversity of environment and physical activity

measures, it is difficult to compare findings across studies. Nonethe

less, high-quality objective measures of both environments and physical

activity, as well as validated self-report measures, do exist, and

the

environmental measures are available at www.activelivingresearch.org

(accessed December 4, 2008). The challenge is for investigators to

use a common core of measures routinely so that key findings can be

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Solutions to the Obesity Epidemic 13 3

replicated in various populations and can facilitate meta-analyses and

pooled analyses.

It is difficult to generalize built environment findings across popula tions or across behaviors. Most studies have been conducted with adults,

and analyses stratified by race, ethnicity, or socioeconomic status are rare.

It thus is a high priority to improve our understanding of environmental

correlates of physical activity and sedentary behaviors in diverse samples,

especially those at high risk for obesity.

Summary of Physical Activity Environment Studies

Living in walkable communities and having parks and other recreation

facilities nearby has been consistently associated with higher levels of

physical activity in youth, adults, and older adults. Several studies of

adults link walkable communities and park access to a lower risk of over

weight and obesity. At least in the United States, however, low-income

populations and communities of color have less access to public and

private recreation facilities. But a few studies go beyond cross-sectional

designs and indicate that behavior may change when individuals move to

new neighborhoods and that building trails can stimulate more people to be physically active. Traffic appears to be a barrier to physical ac

tivity, and school environments have been related to students' physical

activity on campus. Many public health professionals, therefore, con

sider the evidence sufficient to recommend changes in urban planning,

transportation, recreation, and school policies.

Lessons from Research on Food

and Nutrition Environments

Several conceptual models of food and nutrition environments have been proposed (Booth et al. 2001; Story et al. 2008). One useful?and

parsimonious?ecological model for understanding food and nutrition

environments incorporated constructs from the fields of public health, health psychology, consumer psychology, and urban planning (Glanz et al. 2005). The model identified four types of nutrition environments

(community, consumer, organizational, and information) that need to

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134 J'F. Sallis andK. Glanz

be understood, and those environments can be affected by policies of

governments and other organizations (Glanz et al. 2005). This synthesis of knowledge related to food environments?as is the

preceding section on physical activity environments?is based, whenever

possible, on review articles published between 1988 and 2008. Of the

twenty-one review articles, twelve focused on environmental correlates of

eating and/or obesity, and nine on environmental intervention strategies.

Examples of representative studies and policy reports also are provided.

Community Food Environments

The community food environment is defined as the distribution of food

sources, that is, the number, type, location, and accessibility of food

outlets, with stores and restaurants being the most common (Glanz et al. 2005). Many studies have cited both stores and restaurants as

either indicating access to healthful food choices or reflecting high concentrations of often inexpensive foods of low nutritional value.

Food Stores. The presence of food stores appears to contribute to

the eating patterns of neighborhood residents (Ford and Dzewaltowski

2008; Glanz and Yaroch 2004), and racial and ethnic disparities in access to full-service supermarkets frequently have been documented (Morland

et al. 2002; Zenk, Schulz, Hollis-Neely, et al. 2005; Zenk, Schulz,

Israel, et al. 2005). One study found that African Americans' intake

of fruits and vegetables was significantly higher when they lived close to a supermarket (Morland, Wing, and Diez Roux 2002). Accordingly, the availability of supermarkets in neighborhoods was associated with a

better-quality diet (Moore et al. 2008) and a lower prevalence of obesity and overweight in adults (Morland, Diez Roux, and Wing 2006) and

adolescents (Powell et al. 2007). Although those lower-income, minority urban neighborhoods and rural

areas lacking supermarkets

are sometimes

referred to as "food deserts" (Morton and Blanchard 2007), some studies

have found no disparities in access to food stores (Apparicio, Cloutier, and Shearmur 2007; Maclntyre 2007; Pearson et al. 2005).

Restaurants. The proportion of meals eaten outside the home has

increased in the United States (Kant and Graubard 2004). This greater reliance on restaurants could have negative nutritional and health

conse

quences because individuals eating at restaurants more frequently

con

sume, on average, more calories and fat and fewer fruits, vegetables, and

fiber (French et al. 2001; Satia, Galanko, and Siega-Riz 2004; Schmidt

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Solutions to the Obesity Epidemic 135

et al. 2005) and consequently gain more weight (Pereira et al. 2005;

Thompson et al. 2004). Fast-food restaurants in particular have been identified as a poten

tial contributor to a higher prevalence of obesity (Brownell 2004). The

higher concentration of fast-food restaurants in poorer neighborhoods

(Cummins and Macintyre 2002; Powell, Chaloupka, and Bao 2007) thus

is thought to partially explain the higher prevalence of obesity among

economically disadvantaged populations. One analysis found that the

density of fast-food restaurants accounted for 6 percent of the variance

in obesity across the United States (Maddock 2004). However, evi

dence regarding the relationship between individuals' weight status and

the density of restaurants in their neighborhood is weak and has not

been supported in large studies of children and adults in both rural and

urban areas (Burdette and Whitaker 2004; Simmons et al. 2005; Sturm and Datar 2005). One review concluded that the results across studies

were mixed on the question of fast-food density, noting methodological limitations (Papas et al. 2007).

Policy and Environmental Interventions

Related to Community Food Environments

Almost all community food environment studies have been cross

sectional, but efforts are being made to change food environments that

could be evaluated as natural experiments. Although bringing new su

permarkets into disadvantaged areas is not strongly supported by the available research (Cummins and Macintyre 2002; Papas et al. 2007), a moratorium on opening new fast-food restaurants in one poor area

in urban Los Angeles has been proposed (Hoag 2008). As these sorts

of environmental changes gather momentum, it will be important to

evaluate their effects on food-purchasing patterns, eating behaviors, and,

ultimately, weight outcomes.

Consumer Food Environments

Consumer food environments are what consumers encounter within and

around retail food outlets (stores, restaurants, and within-organization food sources) (Glanz et al. 2005). The consumer food environment

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136 J.F Sallis and K. Glanz

constructs of interest include the availability and price of healthful food

choices, quality of food, portion sizes, within-outlet promotions, and

point-of-choice nutrition information (French, Story, and Jeffery 2001; Giskes et al. 2007; Kamphuis et al. 2006).

The target categories of food of broadest interest in retail food stores

are those most closely related to the causes or prevention of obesity and

other chronic diseases. The categories of foods with the highest priority for studies of consumer food environments are dairy products, meat and

poultry, baked goods and sweets, high-fat snack foods, and fruits and

vegetables (Cheadle et al. 1990; Cheadle et al. 1991; Glanz, Sallis, et al.

2007). Variations in consumer nutrition environments may explain some of

the racial/ethnic and socioeconomic disparities in nutrition and health outcomes. Some healthy foods, such as low-fat dairy products (Wechsler et al. 1995) and fruits and vegetables (Horowitz et al. 2004), are less

often available and/or are of poorer quality in minority and lower-income areas. The fewer healthful food options in lower-income neighborhoods and in convenience stores compared with those in supermarkets were

documented in a study in the Atlanta area (Glanz, Sallis, et al. 2007).

Early studies of the availability of healthy foods and individual diets by Cheadle and others found that the availability of low-fat milk and cheese

and lean meats was associated with a lower fat intake by the residents of

surrounding neighborhoods (Cheadle et al. 1990). Assessments of the consumer food environment within restaurants,

including fast-food outlets, have proved to be more challenging than

those at food stores (Cheadle et al. 1994). Recent studies found that only a minority of chain restaurants provide nutrition information about their

main menu items and that when they do, it is usually on websites rather

than at the point of purchase (Saelens et al. 2007; Wootan and Osborn

2006; Wootan, Osborn, and Malloy 2006). An observational study of 217 fast-food and sit-down restaurants

conducted in conjunction with the development of the Nutrition Envi

ronment Measures Survey for Restaurants (NEMS-R) tool found that a

minority of both types of restaurants offered any main dishes that could

be considered healthy by current dietary guidelines, such as fresh fruit, non-fried vegetables, or whole-grain breads (Saelens et al. 2007). The

study had a somewhat paradoxical finding: whereas fast-food restaurants

had more "supersized" choices, promotions of overeating or unhealthy

choices, and "value pricing" for multiple food items, these fast-food

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Solutions to the Obesity Epidemic 137

restaurants were also more likely to offer at least one healthy entree,

to highlight healthy options, and to provide some form of consumer

nutrition information (Saelens et al. 2007).

Policy and Environmental Interventions Related

to Consumer Food Environments

One reason that the distinction between community and consumer food

environments is important pertains to the different potential environ

mental and policy intervention strategies. Consumer food environments are better able to change without "bricks and mortar"

or governmen

tal intervention. That is, individual proprietors and corporations can

change the foods they sell, the information they offer to consumers, their recipes, and their portion sizes, with or without encouragement

from public health professionals. In fact, some local projects have been

working with merchants and restaurateurs to make such changes, though

to date no evaluations have been published. Government policymakers at the local and national levels may be

able to achieve broader changes in consumer food environments but

also must address resistance by the industry. According to interviews

with corporate executives, large restaurant chains' main motivations

are increasing sales and profits, not providing healthful choices (Glanz,

Resnicow, et al. 2007). The most promising, and most active, area for

policy change is providing calorie, fat, and other nutritional information on menus. Such policies

are now in place in two large cities, New York

and Seattle. A health impact assessment of menu labeling finds this

promising, even with conservative estimates of consumers' use of the

information (Simon et al. 2008). As a result, the national debate on

menu labeling is growing more insistent (Berman and Lavizzo-Mourey

2008), and ongoing evaluations should provide valuable information.

School and Worksite Food Environments

School food environments can have a large impact on children's and adolescents' dietary intake because students obtain and eat meals and

snacks at school (see the article by Story, Nanney, and Schwartz in this issue; Story et al. 2008). Designing schools to support healthy eating habits requires policies at both the federal and local levels, as

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138 J.F. Sallis and K. Glanz

well as local implementation, including school nutrition standards and

limiting offerings of competitive foods (IOM 2007). In the past few years, there has been renewed attention to providing support and regulations for healthier school food environments, including expansion of a U.S.

Department of Agriculture fruit and vegetable pilot program, farm-to

school programs that link local farmers providing fresh locally grown

produce to school cafeterias, and federally mandated school wellness

policies (Story et al. 2008). This topic is addressed in greater detail

by Story, Nanney, and Schwartz in this special issue of The Milbank

Quarterly. Few school environment and policy interventions have been eval

uated, despite the School Nutrition Policy Initiative, which contains

school nutrition policies, menu planning, nutrition education, social

marketing, and parent outreach targeting grades 4 through 6. After two

years, significantly fewer children in the intervention schools became

overweight (Foster et al. 2008), thereby demonstrating the potential of

multilevel interventions by schools and communities.

Worksites for adults are comparable to schools for children: they are organizational environments where adults spend most of their days and consume meals and snacks. Several studies showed that changes in worksite environments are feasible and can positively affect food

intake (Engbers et al. 2005). These interventions have achieved healthful

changes in worksite cafeterias (Jeffery et al. 1994) and vending machines

(French et al. 2001). Interventions in worksite settings are described

in greater detail by Heinen and Darling in this issue of The Milbank

Quarterly.

Home Environments

The home is a complex and dynamic food environment and has been

well studied with respect to families' and, particularly, children's eating habits (Story et al. 2008). Food at home is affected by its availability in

the neighborhood (Glanz et al. 2005), and its availability at home and

the influence of parents are especially relevant to children (Bryant and

Stevens 2006; Koplan, Liverman, and Kraak 2004).

Although family outreach has been used as an adjunct to school

based nutrition interventions and obesity treatment in clinical settings, few reports show that home-based interventions improve eating patterns

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Solutions to the Obesity Epidemic 139

(Story et al. 2008). This remains a fertile area for future research. Policies

affecting community and consumer food environments (e.g., proximity to food stores, food prices) are likely to influence home food environments that in turn determine eating behaviors.

Limitations of Available Research

Similar to research on physical activity environments, the cross-sectional

design of most food environment studies is a major limitation (Black and Macinko 2007; Ford and Dzewaltowski 2008; Giskes et al. 2007; Holsten 2008; Papas et al. 2007). Additional prospective studies and

field experiments (planned or "natural") are needed for our knowledge base to expand. In addition, more multilevel intervention studies are

needed, especially those that simultaneously address activity and food environments as they relate to obesity.

The advancement of research partly depends on the availability of

valid, reliable measures of nutrition environments and policies (Glanz et al. 2005). Measures used in research on school food environments,

neighborhood food environments (stores, restaurants), and state poli

cies are illustrative of well-developed measurement tools in this area

(Glanz, Sallis, et al. 2007; Masse et al. 2007; Saelens et al. 2007; Story et al. 2008). But much more work must be done in designing and

testing food environment measures that are feasible for large studies,

adaptable to a

variety of locations, allow for comparability across stud

ies, and provide nutritionally meaningful indicators (Saelens and Glanz

2009).

Summary of Food Environment Studies

Evidence is rapidly growing that proximity to supermarkets is associ ated with an intake of more fruits and vegetables and that proximity to fast-food restaurants is associated with an intake of higher-energy foods and a lower-quality diet. Low-income and racial/ethnic minor

ity communities usually have less access to supermarkets and a greater

concentration of fast-food restaurants, and the quality of foods offered tends to be worse in these neighborhoods. The community food envi ronment has not been consistently related to weight status, as it has

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140 J.F. Sallis and K. Glanz

been difficult to link the quality of food within restaurants with eating behaviors. Most restaurants provide very little nutritional information at the point of decision, although the recent enactment of menu-labeling laws offers an opportunity to evaluate these policy interventions. Food

environment, policy, and pricing interventions have been successful

in promoting healthier choices in schools, workplaces, and vending machines.

Ongoing Efforts to Create Healthier Places for People to Live

Environment, policy, and multilevel strategies for improving diet, phys ical activity, and obesity control are recommended by respected national

and international groups. The World Health Organization (2004) and

the International Obesity Task Force (Kumanyika et al. 2000) strongly recommend environmental and policy changes. In the United States, the surgeon general's call to action to prevent obesity (USDHHS 2001), the Institute of Medicine's report on preventing childhood obesity

(Koplan, Liverman, and Kraak 2004), the Centers for Disease Control

and Prevention (Koplan and Dietz 2000), and an expert panel organized

by the American Medical Association and other organizations (Barlow and the Expert Committee 2007) all concluded that environmental and

policy changes will be essential components of a solution to the obesity

epidemic.

Box 1 highlights efforts to implement environmental and policy

changes, mainly in the United States. A few of these are research

based projects; several are community demonstrations that are being

evaluated; and others are part of organizations' advocacy work. Many

of these initiatives target low-income communities of color because the

people in these communities are at the highest risk of obesity (Ogden et al. 2006), and finding effective solutions for such groups is chal

lenging but urgently needed. These diverse intervention models are

building experience in environmental and policy change, are provid

ing opportunities for research and evaluation, and, we hope,

are offering

lessons that others can use to disseminate effective approaches on a wider

scale.

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Solutions to the Obesity Epidemic 141

BOX 1

Examples of Built Environment Change Strategies in the United States

1. Active Living by Design is working with twenty-five communities across

the country to increase physical activity and healthy eating through community

design, public policies, and communications strategies. It is funded by the

Robert Wood Johnson Foundation, www.activelivingbydesign.org (accessed

December 4, 2008). 2. Healthy Eating Active Communities is working with six communities

in California to demonstrate that by transforming the food and physical activ

ity environments of resource-poor, low-income communities, it is possible to

change norms that foster unhealthy food choices and inactivity. It is funded

by the California Endowment, www.healthyeatingactivecommunities.org (ac

cessed December 4, 2008).

3. Healthy Eating Active Living: Community Health Initiatives is working with twenty-seven communities across the United States to make changes like installing bike racks, getting more fresh fruits and vegetables on the

shelves of corner stores, building walking paths and bike trails, planning safe

routes for kids to walk or bike to school, supporting school cafeteria reforms,

offering physical education in schools, and making health considerations part of planning and development decisions. It is funded by Kaiser Permanente,

http://info.kp.org/communitybenefit (accessed December 4, 2008). 4. New York City's restaurant menu-labeling regulations that require

some restaurants to display calorie information are now in effect; see

www.nyc.gov/html/doh/html/cdp/cdp_pan-calorie.shtml (accessed December

4, 2008). 5. The mission of Philadelphia's Food Trust is to ensure that everyone has

access to healthful, affordable food. Its programs emphasize environments,

policies and education in communities, schools, farmers' markets, and stores; see www.thefoodtrust.org/ (accessed December 4, 2008).

6. Shape Up Somerville is a project in this city near Boston to make environ

mental changes to prevent obesity in culturally diverse, elementary school chil

dren. This intervention is focused on increasing the number of physical activity

options available to children throughout the day and improving dietary choices

in schools and the whole community. It is funded by the Centers for Disease

Control and Prevention, http://www.shapeupsomerville5k.org/aboutsus.html (accessed December 4, 2008), and for evaluation results, see Economos et al.

2007.

7. Smart growth and the new urbanism are related movements that advo cate community designs, transportation investments, zoning ordinances, and

community participation that lead to walkable and environmentally sustainable

neighborhoods and cities. The principal membership organizations are Congress for the New Urbanism (www.cnu.org; accessed December 4, 2008) and Smart

Growth America (www.smartgrowthamerica.org; accessed December 4, 2008).

(Continued)

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142 J.F. Sallis and K. Glanz

BOX 1?Continued

8. PolicyLink is a national research and action institute for economic and

social equity. It provides technical training and capacity building, policy ad

vocacy, and communications training for advocates working to create health

ier communities. These advocates are working to improve socioeconomic and

environmental conditions that affect health and are related to income, seg

regation, pollution, crime, availability of fresh foods and safe recreational

facilities, transit-oriented community design, and accessible quality hous

ing. It has multiple funders; see www.policylink.org (accessed December 4,

2008).

What Is Needed to Accelerate Movement toward Nonobesogenic Environments?

The anticipated health and economic consequences of the obesity epi demic mean that we must find and implement solutions quickly. Because

changes in policy and practice rarely wait for definitive answers from

research, we need to draw lessons from the best available research (a

point well made by the Institute of Medicine; see Koplan, Liverman, and Kraak 2004) and experience from the field. There is, in fact, a great deal of consensus on some promising approaches, and this section dis

cusses some of the principles and practices. As research advances and

experience with environmental and policy intervention deepens, these

approaches should be updated.

Intersectoral Collaboration

Physical activity and food environments are controlled by a wide range of public and private interests involving government agencies at all

levels, multiple major industries, professional organizations, and non

profits. Those sectors of society with obvious relevance are agriculture, food manufacturing and sales, recreation, transportation, education, real

estate, architecture, communication media, advertising, and entertain

ment industries. All these groups are stakeholders, along with the public health, medicine, and health care industries, that need to be engaged in

efforts to create less obesogenic environments. Although some of these

stakeholders will perceive benefits from recommended changes, oth ers will oppose them. A good model of intersectoral collaboration is the

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Solutions to the Obesity Epidemic 143

whole-of-government approach to physical activity promotion pioneered

by New South Wales in Australia (Sallis, Bauman, and Pratt 1998).

Every government department was instructed to promote physical ac

tivity, with an emphasis on environmental and policy change.

Community Engagement and Participation

The involvement of community residents is essential to advocating for, and implementing, changes to create more healthful environments and

policies. Community engagement also is critical to the success of new

initiatives (Minkler, Wallerstein, and Wilson 2008). Even though scien

tists and public health experts may determine that environmental change could help reduce obesity?for example, by restricting the number of

fast-food restaurants in a disadvantaged neighborhood?the residents

may regard such a regulation as punitive or stigmatizing ("blame the

victim") because they depend on cheap, convenient food sources and

lack reliable transportation options. Accordingly, those people living in the neighborhood or working in local organizations should be asked to help identify what is acceptable and promising for increasing the healthfulness of their environments.

Changing Policies on Land Use, Transportation, Recreation, and Building Codes

Zoning ordinances continue to favor low-walkable developments; trans

portation investments for pedestrian and cycling facilities are trivial;

parks are low priorities in many communities; school-siting decisions are not coordinated with community planning; and building codes do not consider physical activity inside and around buildings. Thus every

day, buildings, communities, and roads are constructed that discourage or prevent physical activity, and these built environments will last a

long time. Zoning laws and tax incentives can attract grocery stores

and prevent an excess of fast-food restaurants in communities, demon

strating that policy changes are the key to creating healthy physical activity and food environments. To achieve these policy changes, pub lic health professionals must improve their advocacy skills, develop partnerships with advocacy organizations, and establish intersectoral collaborations.

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144 JF Sallis and K. Glanz

Evaluating, Building the Evidence Base, and Growing Knowledge in Changing Times

Many ideas about changing environments to improve eating and physi cal activity are promising but speculative, so they need to be evaluated

for effectiveness, unintended consequences, and, ultimately, their effects

on health and weight. First-level evaluations should be close to the

change, for example, studying customers at a new

supermarket instead

of conducting a community wide survey that may include few of the new store's customers. Policymakers and public health experts should

thoughtfully construct case studies to better understand how environ

mental and policy innovations will affect their communities. Studies

should be designed to inform policy debates, and the search for evidence

should be both unbiased and multilayered. Connections with Climate Change and Energy Policy. Similar to obesity,

the predicted consequences of climate change are near the top of the

public agenda (Ewing et al. 2008). Many actions recommended to con

trol obesity are also expected to decrease carbon emissions. Reducing

driving by walking and cycling more helps solve several problems, and

people living in walkable neighborhoods are estimated to generate about

30 percent less carbon than suburban residents do, largely because they

drive less (Ewing et al. 2008). More compact, walkable development patterns can preserve (1) forests that absorb carbon, (2) open space where

people can be physically active, and (3) farmland that enhances access

to local produce while reducing carbon from transporting food long distances. Policies with beneficial effects for both obesity and climate

change need to be evaluated, and opportunities for collaboration with

the environmental protection movement should be considered.

A New Environmental Education

Some of the success of the environmental protection movement has been

attributed to effective educational curricula in schools (Economos et al.

2001), many of which include hands-on learning. Teaching students

about their food and physical activity environments could produce a

generation of advocates for healthy community environments. Examples

of class projects are observations of the food and physical activity envi

ronments in their local areas, surveys of community preferences, com

parison of results with neighborhoods of contrasting sociodemographic

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Solutions to the Obesity Epidemic 145

characteristics, written reports, and the presentation of findings and

recommendations to community leaders. These activities could be inte

grated into health, science, social studies, math, and physical education

lessons. This is a topic ripe for research.

Additional strategies that engage the community, involve multiple stakeholders, and strengthen advocacy need

to be developed, evaluated,

and refined to implement the evidence-based policy changes expected to

lead to nonobesogenic food and physical activity environments. Even

though widespread environmental changes may take years to show

results, the beneficial effects can be expected to contribute to long

lasting improvements in physical activity, eating, and obesity.

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Acknowledgments: Work on this article was supported by the Active Living Research Program of the Robert Wood Johnson Foundation, NIH grant HL083454 (Sallis), and a Distinguished Research Scholar Award from the

Georgia Cancer Coalition (Glanz).

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