Designing for Healthy Communities: Active Living and Comprehensive Community Development

by Xuemei Zhu and James F. Sallis
Published: December 12, 2011

Limiting obesity—which is closely linked to several chronic diseases and is sharply on the rise in the U.S.—has become a public health priority in this country. Recently there has been a paradigm shift in how policymakers view efforts to reduce obesity, from a focus on individual behavior to a wider understanding of the role of personal, interpersonal, organizational, community and public policy factors. The active living field aims to improve health by incorporating physical activity into the daily routine.

To support active living, proponents focus on many factors of the urban built environment, including safe streets, compact land development, local parks and other green space, and well-designed local schools. This paper from Active Living Research offers a summary of empirical evidence that can be used by community developers to add a public health component to their work. It can be used in projects that range from local economic development to public safety campaigns, as well as serving as an introduction to the field of active living as potential allies and partners in community development.

Health has been and continues to be one of the ultimate goals in people’s lives. Living in a “healthy community” is everyone’s dream, yet what that is and where to find it can be difficult questions. Many families move into suburban communities, expecting more living space, clean air, lawns and gardens, fewer urban hassles and great places for children to play—all leading to better health. But the work place, school and grocery store are further away and require more driving, which is sedentary and often stressful. Time for family or exercise is more difficult because of a longer commute. Children spend more time in front of television or video games, as there are “dangerous traffic and strangers” outside and no watchful neighbors’ “eyes on streets.”

Urban communities may have advantages that have been forgotten: mixed land use means stores, schools and jobs can be accessed by walking; commute times are shorter; and parks and sidewalks can allow children more opportunities to play. City communities, however, do not guarantee opportunities for a healthy life. A child’s school may be nearby, but the walk may be unsafe because of crime, gangs or traffic. Or there may be no safe and well-maintained park, play area or other usable green space nearby.

What does it mean to have a healthy community? How do you find them? What can be done to promote health in urban communities?

Community planners, designers, developers and government officials must consider a vast array of potential consequences of their decisions around land development, including the effects on housing, employment, transportation, economics, schools and education, parks and recreation, social equity and quality of life. For health concerns, there is growing interest in the effects of community design on active living, healthy eating, obesity and related chronic diseases such as heart disease, diabetes and cancers.¹ These inter-related health issues account for at least 70 percent of all deaths in the U.S. and a large share of health care costs.²

Obesity, through its relation to several chronic diseases,³ is responsible for nearly one in 10 deaths⁴ and an estimated 112,000 preventable deaths each year in the U.S.⁵ The prevalence of obesity has increased dramatically since about 1980, tripling among children and doubling among adults.⁶ Lower-income and racial and ethnic minority populations are at higher risk of obesity at all ages.⁷

For the majority of individuals, being overweight or obese results from an energy imbalance. On one hand, they eat in an unhealthy manner with an excessive energy intake that contributes to obesity, and an inadequate consumption of nutritionally dense foods like fruits and vegetables that reduce risk of cardiovascular diseases and cancers.8 On the other hand, their energy expenditure is insufficient due to physical inactivity, which is the fourth leading cause of death due to chronic diseases.⁹

In contrast, physical activity helps to prevent obesity and has numerous additional health benefits.¹⁰ Public health recommendations are for healthy adults to engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity per week, or a combination. For children and adolescents, the recommendations are to engage in at least 60 minutes of moderate- to vigorous-intensity aerobic physical activity each day.¹¹ The majority of adults and youth are not meeting these recommendations,¹² putting most Americans at risk. Based on activity monitors, fewer than half of children, 10 percent of adolescents and 5 percent of adults in the US are meeting these guidelines.¹³

Traditional health promotion and behavior change interventions target psychological and social factors to change individual behaviors, but these have not been successful in achieving sustained effects.¹⁴ Recently, there has been a paradigm shift from individual-focused models to ecological models, which consider human behavior to be influenced by multi-level factors (e.g., personal, interpersonal, organizational, community and public policy factors). As a result, recommendations are for comprehensive, multi-level interventions.¹⁵

Interdisciplinary approaches have been increasingly used to address the potential of built environmental and policy changes in promoting population-level behavior changes.¹⁶ To promote physical activity, the focus has shifted from exercise to active living—“a way of life that integrates physical activity into the daily routine,”¹⁷ involving multiple fields such as public health, behavioral science, urban planning, transportation, parks and recreation, urban design, landscape architecture and architecture.¹⁸ For healthy eating, the focus is shifting from nutrition education to changing the food environment on community, consumer, organizational and information levels, incorporating disciplines such as public health, health psychology, consumer psychology and urban planning.¹⁹

There is a significant overlap between the fields of active living and healthy eating and comprehensive community development in theoretical basis, goals and approaches. All three fields embrace a comprehensive (instead of “piecemeal”) approach with systems thinking.²⁰ They consider human behavior (for active living and healthy eating) or communities (for comprehensive community development) to be influenced by complex systems of multi-level factors.²¹ Their goals are in support of sustainability (e.g., more walking and biking and less driving), economic development (e.g., more locally grown produce and more viable local businesses as daily walking/biking destinations), health and quality of life. They all address the importance of local context and tailored strategies. Communities, especially their public places (e.g., schools, parks, open spaces, recreational centers and local grocery stores), are important settings for promoting active living, healthy eating, and development.

The State of Knowledge about Built Environment and Physical Activity

There is a large and growing body of evidence on the relationship between the built environment and physical activity²² and obesity.²³ The Centers for Disease Control and Prevention’s Active Community Environments program and the National Institute of Health’s Obesity and the Built Environment initiative were key supporters of earlier research. Since 2001, theRobert Wood Johnson Foundation’sActive Living Researchprogram provided the most sustained and targeted early funding for this field.²⁴ It supported studies to develop measurement tools for built environment and physical activity, establish an evidence base of environmental and policy factors related to physical activity, evaluate innovative interventions in communities, build the capacity of interdisciplinary teams, and use the results to stimulate and inform policy changes.²⁵

The literature has informed the recent upsurge of multi-level environmental and policy interventions to promote physical activity in occupation, recreation,transportation andhousehold domains. Different environmental factors have been found to be related to each domain of physical activity, especially the transportation and recreation domains,²⁶ and this information can be applied by community designers and planners. Authoritative organizations in the U.S. and other countries recommend environmental and policy changes as essential to meeting physical activity guidelines and obesity control goals.²⁷

Disparities in Access to Health-Promoting Environments

Lower-income and racial and ethnic minority populations have disproportionately higher risk for obesity.²⁸ Built environments may have played a role in this disparity, and there is mounting evidence these groups are disadvantaged in access to built environments that support active living or healthy eating. Lower-income and minority populations are actually more likely to live in highly walkable areas (with greater density, street connectivity and land-use mix) that promote active transportation. However, their communities also tend to be less pleasant places to walk in, unsafe because of traffic, crime, and social disorder, and lacking social cohesion,²⁹ all of which may undermine the benefits of walkable community patterns.

Access to and quality of recreational facilities such as parks, trails, open spaces and private recreational facilities is often lower in low-income, low-education and minority communities, at least in the U.S.³⁰ Research has also shown disparities in school physical activity. A study reported lower facility provision in schools that most need them—those located in urban areas, with high percentages of minority students, or with high enrollment.³¹ Socioeconomic disparities also exist in the access to healthy foods. A review of 54 studies found that lower-income, minority and rural neighborhoods had poorer access to supermarkets and healthful food while their availability of fast-food restaurants and high-fat, unhealthy foods was greater.³² Studies in New York City found that predominantly African-American schools or neighborhoods had more fast food nearby than mostly white neighborhoods.³³ Other studies show these environmental inequalities are likely to have important effects on health.

Walkable Communities

“Walkable communities” have higher density, mixed land uses (e.g., homes, work places, schools, shops and parks), and well-connected street networks (Figure 1). They support physical activity, especially active transportation (walking and biking).³⁴ This association is supported by substantial literature and recognized by leading agencies such as the Transportation Research Board, the Institute of Medicine³⁵ and the Centers for Disease Control’s Task Force for Community Preventive Services.³⁶ Walkable communities make everyday destinations closer to each other, enable the connection of daily activities through short walking/biking/transit trips, and make driving less necessary or even less desirable because it takes more time and costs more. A weaker but growing body of evidence indicates that other features such as rich pedestrian/bicyclist infrastructure (sidewalks, bike lanes and traffic calming), good visual quality and maintenance, and safety from traffic and crime may provide additional support for walking and biking.³⁷

Since about 1950, most communities in the U.S. have been designed to optimize automobile travel. Density is low; streets are disconnected; land uses are separated as required by zoning laws; and pedestrian and biking facilities are either an afterthought or absent. However, becoming a walkable community can be a goal for not only new communities but also existing ones; for example, through infill development with mixed land uses that also revitalize the local economy.

Study examples show the positive health effects of designing communities that allow people to safely walk from place to place. In a U.S. study conducted in the Seattle and Baltimore regions, the association between walkability (land-use mix, street intersection density, residential density and pedestrian-friendly design of retail areas) and physical activity translated into 34 to 47 more minutes of total physical activity per week in high-walkable neighborhoods, asmeasured by accelerometers—electronic devices attached to the body to capture body movement.³⁸ The same study found significantly lower rates of overweight and obesity among residents of high-walkable neighborhoods. The health effects of walkability were similar in lower-income and higher-income adults, suggesting environmental changes could help reduce health disparities.³⁹

An Australian study showed a dose-response relationship between the mix of destinations (post boxes, bus stops, convenience stores, news agencies, shopping malls and transit stations) and walking for transportation. Each additional type of destination within 400 meters (about 0.25 mile) and 1,500 meters (about one mile) resulted in five to six additional minutes per week walking for transport.⁴⁰ A recent review of youth studies found that the mixed-use component of walkability was among the most consistent correlates of child and adolescent physical activity.⁴¹ Studies on the impact of environmental changes on physical activity changes are limited but have shown some promising results. For example, a study in North Carolina reported a causal relationship between moving to a more walkable neighborhood and an increase of self-reported physical activity.⁴²

Walkable communities also have the potential to promote community development by generating economic, environmental and social benefits. First, walkable communities are economically viable. Higher density can make jobs more accessible and facilitate the success of local businesses and public transit systems; reduced automobile use (or even ownership) can bring financial saving to residents; housing developments that benefit from enhanced walkability to retail, services, transportation, parks and other amenities⁴³ may sell or lease for higher prices than low-density, automobile-dependent development.⁴⁴ Recent studies have shown a growing demand and strong market acceptance for walkable communities.⁴⁵

Second, walkable communities can generate environmental benefits by reducing automobile use and vehicle emissions and by preserving natural areas through more compact development. Further, walkable communities may encourage social interactions and foster a stronger sense of community and social capital, and thereby, promote community development.

Land uses also affect food access in the community and influence obesity by their impact on healthy eating.⁴⁶ A review of 54 studies found that individuals with better access to supermarkets and limited access to fast-food restaurants had healthier diets and lower rates of obesity.⁴⁷ Higher residential density, convenient multi-mode transportation systems, and vital community economics may attract more healthy food outlets into the community. Zoning that encourages or requires walkable communities can help preserve local farmland, enhancing access to local produce.

Policies influencing these community elements are land-use and zoning codes (e.g., those related to mixed use and density), building codes (e.g., regulations about orientation to the street, parking requirements and visual quality) and transportation policies (e.g., roadway design standards and sidewalk requirements). Traditionally, physical activity benefits were not considered in these policies. Nowadays, a growing number of local governments are recognizing such health benefits and employing more comprehensive approaches.⁴⁸

Walkable Streets

Streets are the transportation infrastructure in communities, serving the movement of people and goods and allowing access to jobs, schools, recreation and other destinations. Well-designed, walkable streets can also serve as health infrastructure by offering safe places for active transportation and recreation, providing access to restorative natural environments,⁴⁹ and fostering social interactions (Figure 2).

In the classic book “The Death and Life of Great American Cities,” Jane Jacobs⁵⁰ discussed impacts of streets on safety, sense of community and children. She also criticized her era’s urban renewal for isolating communities and destroying street life. Five decades later, many American communities still struggle with the loss of streets’ economic, social and physical vitality associated with designing them to serve only cars. Some active living studies have found community streets to be a popular destination for walking—the most common type of physical activity⁵¹—implying streets’ central role in promoting physical activity and bringing social life, surveillance and safety back to communities.

Theory and practice in urban design, urban planning and transportation offer some general guidance on the relation of street design to physical activity. Empirical evidence in this area is limited but growing. For example, in an international study, “sidewalks in the neighborhood” was the strongest environmental correlate of adults’ physical activity.⁵²

It is desirable to develop complete and connected sidewalks equipped with smooth walking surface and sufficient amenities (e.g., greenery, protection from severe rain or heat, adequate lighting and benches). When the streets accommodate busy or high-speed traffic, landscape or other types of buffers should be used to protect pedestrians from vehicle traffic. Land uses along the street should provide a mix of attractive destinations, and buildings should be designed with human scale and visual interest to further encourage walking. Public/civic spaces (e.g., plazas, pocket parks) should be provided as attractive nodes⁵³ of the street system and the community, with good amenities and visual quality, connected to the transit system and integrated into the surrounding area. Increased pedestrians, bicyclists and social interactions also provide “eyes on streets” for better surveillance and safety.⁵⁴

It is possible for communities or towns with a traditional main street to use the thoroughfare as the hub for active living and healthy eating by developing pedestrian amenities, bringing in attractive local businesses (including grocery stores and restaurants offering healthy foods), adaptively reusing historical buildings and offering convenient transit. All of these activities are often goals for economic development; by increasing the walkability of the neighborhood, they provide health benefits as well.

Street conditions may be particularly important for children. After distance to school, the main parental barrier to children’s active commuting to school is traffic safety. A single dangerous intersection or busy road barrier, especially a freeway, reduces the likelihood that a child will walk to school.⁵⁵ Positive sidewalk characteristics, safe street crossings and traffic calming features (e.g., speed bumps, traffic lights) were associated with greater total physical activity among youth.⁵⁶ One study found that children with busy streets near their homes gained more weight over eight years than children without such streets, likely because heavy traffic leads to less walking and bicycling in the neighborhood.⁵⁷

An important age difference should be noted on the topic of how physical activity is impacted by street connectivity—whether streets are linked together or are dead ends. Although higher street connectivity promotes physical activity among adults,⁵⁸ reversed associations have been reported among children.⁵⁹ The interpretation is that children can use cul-de-sacs as low-traffic play areas. This inconsistency points out that we need to remain aware of the complexity of built environment—physical activity relationships, which are often specific to the physical context, domain of activityor population characteristics.⁶⁰

Note that community streets are influenced byland-use, zoning codes andtransportation policieslike road design standards and sidewalk requirements. The lack of collaboration across agencies may make activity-friendly development difficult. For example, the Fire Department may disapprove the design proposal for narrower streets intended to slow automobile traffic, citing a concern of limited space for fire trucks. A business route of a state highway may be managed by the State Department of Transportation, making it difficult for the local municipal government to implement pedestrian-friendly infrastructure changes.

Parks, Trails, Open Spaces and Other Recreational Facilities

Recreational facilities can be publicly provided (e.g., public parks, open spaces, playgrounds, trails and community recreation centers) or privately owned (e.g., health clubs or exercise facilities at home). Both types can encourage recreational physical activity, and public facilities with activity-friendly features can promote population-level changes (Figure 3). In a review of studies on recreational facilities and physical activity, about 80 percent of the studies showed some significant results.⁶¹

Proximity to parks or other recreation settings was the most studied attribute in these papers and was consistently reported to be positively associated with physical activity among adults⁶² and children.⁶³ One mile was recommended as a reasonable distance to parks,⁶⁴ although that figure should be considered within specific contexts (e.g., availability of private vehicles or presence of freeway barriers). Other park attributes such as activity facilities (e.g., trails, open fields, pools, tennis courts), park size, aesthetics, amenities (e.g., drinking fountains, bathrooms, trash cans), maintenance and cleanliness are less studied, and the research results on their impact so far have mixed results.

Trails may be particularly important public spaces for physical activity, because almost all trail users are active, and trails can be used for both transportation and recreation. One study reported trails to be most strongly associated with physical activity among various park facilities.⁶⁵ A study of trails in three cities found that the presence of excellent trail conditions, streetlights and cafes were associated with increased trail use.⁶⁶ The access to and quantity of recreation facilities and amenities, as well as their quality should be considered for people of all ages, activity preferences and income levels.

Parks and other recreational facilities also can often be used as settings for important community events, including health-promotion activities. They may be both the “green lung” of the community and also the “social core” that can boost social capital and community capacity. In addition, they often bring economic values to nearby properties and contribute proportionately higher property tax revenues for local governments.⁶⁷ A review of about 30 studies suggests a 20 percent increment on property values from abutting or fronting a passive park area.⁶⁸ If the park is heavily used, the proximate value increment may be minimal on abutting properties, but may reach 10 percent on properties two or three blocks away.⁶⁹

Policy support on regional and local levels is needed to ensure the provision of accessible and quality parks and open spaces for all types of communities. Comprehensive master plans should incorporate considerations of parks and open spaces and address their multi-faceted impacts on the natural environment, human health and community development. Partnerships between local governments and developers (e.g., policy incentives for developers to protect and invest in parks and open space) may facilitate the development of public recreational facilities.

Neighborhood Schools

A local school can serve as a community hub and, as one of the largest capital investments for most local governments and school districts, it can promote comprehensive community development by influencing the local environment, health, transportation, social equity and local finance.⁷⁰ In terms of the economy, distant schools often contribute to the migration away from existing cities and towns, which can cause disinvestment and hurt local economies. By contrast, neighborhood schools can improve property values, support local businesses and serve as catalysts for revitalization.⁷¹ In terms of environment and health, schools in distant locations increase automobile traffic congestion and air pollution.⁷² From the social aspect, distant schools are less likely to become anchors of the community or encourage community interaction, engagement and pride.⁷³

Schools are also important settings for promoting active living and healthy eating. Centrally-located neighborhood schools can promote active school transportation of walking and biking (Figure 4). They also can improve school children’s access to physical activity resources in the community. Rich physical activity facilities at school or shared use of facilities between school and other local institutionscan further promote children’s and residents’ active recreation.

Walking and biking to/from school can be an important source for daily physical activity among school-aged children. However, in the past few decades, walking and biking to school has decreased dramatically in the U.S., from 40.7 percent in 1969 to 12.5 percent in 2011.⁷⁴ Distance is the strongest correlate of active commuting to school,⁷⁵ but many schools have been built in more distant locations to accommodate larger campuses and/or because the land was less expensive.⁷⁶ Other environmental characteristics such as traffic barriers (e.g., freeway, busy intersections), lack of pedestrian infrastructure (e.g., sidewalks, safe pedestrian crossings) and safety concerns are also important barriers to active school transportation.⁷⁷

School design, together with school policies and programs, influences the amount of physical activity that students engage in during school hours. A study of 10 middle schools found that larger campuses and buildings and more play areas per student promoted physical activity.⁷⁸ The differences in these 10 schools’ design factors led to a 20 to 30 percent difference in total physical activity during school hours, which translates to an increase of approximately 34 calories per day or walking two extra miles per week, independent of other factors. In another study of 24 public middle schools, environmental features of physical activity areas such as the area’s type and size explained 42 percent of the variation in the proportion of girls who were physically active and 59 percent of the variation for boys.⁷⁹ A few intervention studies have demonstrated the potential of schoolyard or playground renovations as low-cost strategies to improve students’ physical activity.⁸⁰

The goals of walkable distance for a community school and larger campuses may conflict when decisions are being made for location. In such cases, comprehensive decision-making is needed to balance different factors. It should be noted that centrally-located neighborhood schools can utilize existing facilities in the neighborhood to compensate for the possible loss in the size of campus and in-school play areas, and may offer a more cost-effective approach to school development. Neighborhood school facilities also can be used for community meetings and adult education classes, and indoor and outdoor facilities can be used by residents for physical activity. However, school policies often prohibit such use due to concerns of legal liability, staffing, cost and maintenance.⁸¹

Policy changes have been recommended to improve the impact of schools on health through both environmental interventions and educational programs.⁸² First, joint use agreements can be developed between schools and park departments or other recreation providers to share facilities (and costs) to allow broader community use of existing resources for physical activity and other purposes.⁸³ One example is the Learning Landscapes program in Denver. Landscape architects worked with the school district to renovate school grounds in low-income neighborhoods. With extensive community input, school grounds also became neighborhood parks. An evaluation showed that the renovations increased children’s physical activity.⁸⁴

Second, to facilitate the development of centrally-located neighborhood schools, decision makers can consider policy interventions to limit minimum acreage requirementsandfunding formulas that favor the development of large, new schools in relatively remote areas, over the renovation of existing neighborhood schools. Between 2003 and 2007, three states (South Carolina, Rhode Island and Maine) abandoned minimum acreage requirements for new schools.⁸⁵ Comprehensive considerations and collaborative processes are needed for the decisions regarding the locations of schoolsandthe designation of attendance areas, and attention should also be given to school transportation (e.g., the possibility of walking/biking to school and the cost of busing students).⁸⁶

Another school factor that can impact health is the school food environment. Up to 50 percent of students’ total daily energy intake can be consumed at school.⁸⁷ The availability of snacks and drinks sold in schools through snack bars, stores or fund-raisers have been related to higher intakes of total energy, soft drinks, total fat and saturated fat, and lower intakes of fruits, vegetables and milk.⁸⁸ Interventions to improve the school nutrition environment have been found to be feasible and effective, and may be implemented without reducing school revenues. Examples of such interventions include competitive pricing and promotions for fruits, vegetables and low-fat foods⁸⁹ or requiring school snack bars to offer only individual portions of foods and beverages.⁹⁰ Combinations of these strategies appeared to be most effective.⁹¹

Limitations and Future Directions of Active Living Research

Researchers are increasingly studying policy interventions and economic values of active living environments⁹² to mitigate several limitations in the field. Most previous studies are cross-sectional in nature and subject to the criticism of self-selection bias and the inability to establish causal relationships. A small yet growing number of studies are using prospective, quasi-experimental (“natural experiment”) designs⁹³ and offering insights into causal relationships.⁹⁴ Newer studies are examining how the findings summarized above may vary according to the context orpopulation-specific characteristics, such as race, ethnicity, socioeconomic status or geographic locations.⁹⁵ Also growing is the effort to examine more detailed environmental measures and to establish how much of each environmental attribute is needed, so that results can better inform the design and policy-making process.⁹⁶

Conclusions and Discussions

Both comprehensive community development and active living fields pursue comprehensive approaches that actively engage multiple stakeholders. Comprehensive community development employs integrated, inclusive and systematic approaches and views neighborhoods as complex systems influenced by the larger interactive systems and neighborhood characteristics such as building stock, location and transportation infrastructure.⁹⁷ The field calls for “broad engagement of stakeholders with local knowledge and capacity, development of strategies which are simultaneously integrated, comprehensive and flexible, and institutional capacity to sustain on-going engagement, adaptation and execution.”⁹⁸

This framework is consistent with the ecological models behind active living and healthy eating that posit multi-level interventions that change people, environments, and policies are needed to be effective.⁹⁹ To achieve active living goals, policy makers in city planning, transportation, parks and recreation, education, housing, social services, medicine and public health must be engaged. To achieve the policy changes that will produce activity-friendly environments, community voices must guide the specific nature of the changes based on the context, to generate political support.

Both initiatives require deep, local knowledge of neighborhoods and context-based, tailored strategies for effective and sustainable interventions. Active living promotes the integration of physical activity into daily routines (e.g., walking and biking for daily tasks), which is most likely to take place in local communities. Comprehensive community development also highlights the importance of local communities and considers them as the “front lines and building blocks” for successful development.¹⁰⁰

Comprehensive community development addresses sustainability, economic development, health and quality of life. A physically active lifestyle (active living) provides synergetic effects on these goals, not only through a healthier population, but also through sustainability (e.g., by reducing automobile dependence), social interaction, quality of life and economic benefits for the community. Successful community developments help build the social and physical infrastructure for active living. They can address disparities in environmental opportunities for healthy life, and thereby, offer a major opportunity to reduce such disparities and advance Americans’ health.¹⁰¹

With the increasing recognition of the relationship between physical environment and physical activity and its potential to help curb the obesity epidemic, fields such as community development and active living have much common ground. Many professionals working to achieve active living would like to become involved in community development, and their expertise may help make community development even more comprehensive. By combining ideas and learning from each field, we can enhance both health promotion and community development.

James F. Sallis, director of Active Living Research, recently moved from the department of psychology at San Diego State University to the department of family and preventive medicine at University of California, San Diego. His primary research interests are promoting physical activity and understanding policy and environmental influences on physical activity, nutrition, and obesity. He is an author of more than 500 scientific publications, co-author of several books and on the editorial boards of several journals. His current focus is using research to inform policy and environmental changes that will increase physical activity and reduce childhood obesity.

Notes

1  H. Frumkin, L. Frank, R. Jackson, The Public Health Impacts of Sprawl, Island Press, Washington, DC (2004).

2  P. L. Remington, R. C. Brownson, M. V. Wegner, eds., Chronic Disease Epidemiology and Control, American Public Health Association, Washington, DC (2010).

3  The Surgeon General’s Vision for a Healthy and Fit Nation 2010, Office of the Surgeon General, U. S. Department of Health and Human Services, Rockville, MD (2010).

4  G. Danaei, E. L. Ding, D, Mozaffarian, B. Taylor, J. Rehm, C. J. Murray, et al., “The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors,” PLoS Med (2009).

5  K. M. Flegal, B. I. Graubard, D. F. Williamson, M. H. Gail, “Excess deaths associated with underweight, overweight, and obesity,” The Journal of the American Medical Association (2005).

6  C. L. Ogden, M. D. Carroll, L. R. Curtin, M. A. McDowell, C. J. Tabak, K. M. Flegal, “Prevalence of overweight and obesity in the United States, 1999-2004,” JAMA (2006). The Surgeon General’s Vision for a Healthy and Fit Nation 2010, Office of the Surgeon General, U. S. Department of Health and Human Services, Rockville, MD (2010).

7  C. L. Ogden, M. D. Carroll, L. R. Curtin, M. A. McDowell, C. J. Tabak, K. M. Flegal, “Prevalence of overweight and obesity in the United States, 1999-2004,” JAMA (2006). Y. Wang, M. A. Beydoun, “The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis,” Epidemiol Rev (2007).

8  Dietary Guidelines for Americans 2010, U.S. Department of Agriculture, U.S. Department of Health and Human Services, Washington, DC (2010).

9  G. Danaei, E. L. Ding, D, Mozaffarian, B. Taylor, J. Rehm, C. J. Murray, et al., “The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors,” PLoS Med (2009). The Surgeon General’s Call To Action To Prevent and Decrease Overweight and Obesity, U.S. Department of Health and Human Services (2001).

10    Physical Activity Guidelines for Americans, U.S. Department of Health and Human Services, Washington, DC (2008).

11    Physical Activity Guidelines for Americans, U.S. Department of Health and Human Services, Washington, DC (2008).

12    Physical Activity Guidelines Advisory Committee Report, U. S. Department of Health and Human Services, Washington, DC (2008). R. P. Troiano, D. Berrigan, K. W. Dodd, L. C. Masse, T. Tilert, M. McDowell, “Physical activity in the United States measured by accelerometer,” Medicine and Science in Sports and Exercise (2008).

13    R. P. Troiano, D. Berrigan, K. W. Dodd, L. C. Masse, T. Tilert, M. McDowell, “Physical activity in the United States measured by accelerometer,” Medicine and Science in Sports and Exercise (2008).

14    J. F. Sallis, M. A. Adams, D. Ding, “Physical activity and the built environment,” The Causes and Correlates of Diet, Physical Activity, In press. J. F. Sallis, R. B. Cervero, W. Ascher, K. A. Henderson, M. K. Kraft, J. Kerr. “An ecological approach to creating active living communities,” Annual Review of Public Health (2006). J. P. Koplan, C. T. Liverman, V. I. Kraak, eds., Preventing Childhood Obesity: Health in the Balance, The National Academies Press, Washington, DC (2005).

15    J. F. Sallis, R. B. Cervero, W. Ascher, K. A. Henderson, M. K. Kraft, J. Kerr. “An ecological approach to creating active living communities,” Annual Review of Public Health (2006). K. R. McLeroy, D. Bibeau, A. Steckler, K. Glanz, “An ecological perspective on health promotion programs,” Health Education & Behavior (1988). J. F. Sallis, N. Owen, E. B. Fisher, Ecological Models of Health Behavior, Jossey-Bass, San Francisco, CA (2008). Physical Activity and Health: A Report of the Surgeon General, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health,U.S. Department of Health and Human Services (1996).

16    J. F. Sallis, M. A. Adams, D. Ding, “Physical activity and the built environment,” The Causes and Correlates of Diet, Physical Activity, In press. J. F. Sallis, K. Glanz, “Physical activity and food environments: solutions to the obesity epidemic,” Milbank Quarterly (2009).

17    Active Living Research.

18    J. F. Sallis, R. B. Cervero, W. Ascher, K. A. Henderson, M. K. Kraft, J. Kerr. “An ecological approach to creating active living communities,” Annual Review of Public Health (2006). J. F. Sallis, K. Glanz, “Physical activity and food environments: solutions to the obesity epidemic,” Milbank Quarterly (2009). C. P. Durand, M. Andalib, G. F. Dunton, J. Wolch, M. A. Pentz, “A systematic review of built environment factors related to physical activity and obesity risk: implications for smart growth urban planning,” Obesity Review (2011).

19    K. Glanz, J. F. Sallis, B. E. Saelens, L. D. Frank, “Healthy nutrition environments: concepts and measures,” Am J Health Promot (2005). M. Story, K. M. Kaphingstm, R. Robinson-O’Brien, K. Glanz, “Creating healthy food and eating environments: policy and environmental approaches,” Annual Review of Public Health (2008).

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93    Active Living Research. L. A. Brink, C. R. Nigg, S. M. Lampe, B. A. Kingston, A. L. Mootz, W. van Vliet, “Influence of schoolyard renovations on children’s physical activity: the Learning Landscapes Program,” American Journal of Public Health (2010). T. A. Farley, R. A. Meriwether, E. T. Baker, L. T. Watkins, C. C. Johnson, L. S. Webber, “Safe play spaces to promote physical activity in inner-city children: results from a pilot study of an environmental intervention,” American Journal of Public Health (2007). N. M. Wells, Y. Yang, “Neighborhood design and walking. A quasi-experimental longitudinal study,” American Journal of Preventive Medicine (2008).

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96    F. James, K. G. Sallis, “Physical activity and food environments: solutions to the obesity epidemic,” Milbank Quarterly (2009).

97    R. Weissbourd, “Lessons from the field: how 21st century community development can inform federal policy,” The Journal of the Institute for Comprehensive Community Development (2010).

98    R. Weissbourd, “Lessons from the field: how 21st century community development can inform federal policy,” The Journal of the Institute for Comprehensive Community Development (2010).

99    J. F. Sallis, R. B. Cervero, W. Ascher, K. A. Henderson, M. K. Kraft, J. Kerr, “An ecological approach to creating active living communities,” Annual Review of Public Health (2006).

100  R. Weissbourd, “Lessons from the field: how 21st century community development can inform federal policy,” The Journal of the Institute for Comprehensive Community Development (2010).

101          D. R. Williams, J. Marks, “Community development efforts offer a major opportunity to advance americans’ health,” Health Aff (Millwood) (2011).

Posted in Journal Volume 2, Number 2 -- December, 2011

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