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Introduction

The built environment—the physical world made up of the homes, buildings, streets, and infrastructure within which people live, work, and play—underwent changes during the 20th and 21st centuries that contributed to a sharp decline in physical activity and affected access to healthy foods. Those developments contributed in turn to the weight gain observed among Americans in recent decades (IOM, 2012; Sallis and Glanz, 2009; TRB and IOM, 2005). Many believe, therefore, that policies and practices that affect the built environment could affect obesity rates in the United States and improve the health of Americans (IOM, 2012).

A workshop titled Advancing Obesity Solutions Through Investments in the Built Environment¹ was held on September 12, 2017, to improve understanding of the roles played by the built environment in the prevention and treatment of obesity and to identify promising strategies in multiple sectors that can be scaled up to create more healthful and equitable environments. The workshop was convened by the Roundtable on Obesity Solutions, which is part of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine.

Bill Purcell, currently with Farmer Purcell White & Lassiter, PLLC, and former mayor of Nashville, Tennessee, introduced the workshop and

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¹ The planning committee’s role was limited to planning the workshop, and this Proceedings of a Workshop was prepared by the workshop rapporteur with staff assistance as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

presented background on the roundtable. Box 1-1 summarizes Purcell’s description of the roundtable, and Box 1-2 provides the full statement of task for the workshop. As stated in the workshop agenda (see Appendix A), the workshop’s objectives were to

OVERVIEW OF THE BUILT ENVIRONMENT

In his introductory remarks, James Sallis, distinguished professor of family medicine and public health, University of California, San Diego, provided a broad overview of how the built environment can affect weight. Throughout most of human history, he noted, the structure of cities was based on the assumption that people would walk wherever they wanted to go. Even in the first part of the 20th century, he observed, people walked on the streets despite having to dodge obstacles such as horses, streetcars, and other pedestrians. Then, he said, motor vehicles took over the streets, and “everything changed.” “This may be one of the biggest experiments in human history,” he added, “and we are now starting to evaluate the outcomes on health.”

Other changes in the built environment have also had potential effects on physical activity and weight, Sallis observed. He cited zoning laws that separated residential, commercial, and industrial uses and increased the distances between homes, jobs, and commerce, which in turn affected walking. Many towns and cities became spread out along roads, he explained, making them “no longer scenic or functional because [people had to] drive

just about everywhere.” He pointed out that these same roadways became cluttered with large, eye-catching signs and billboards that often advertised unhealthy foods. The result, he argued, has been a built environment that discourages physical activity and encourages unhealthy eating.

Sallis then noted that the impact of these changes on obesity is a question that was rarely even asked before the 21st century. Investigating the relationships between the environment and obesity called for developing new collaborations, models, and methods, he observed; “it was not just applying the same old ideas and methods to a new question.” He and his colleagues documented the increase in research on policy and environmental impacts on nutrition and physical activity by looking at research abstracts presented at conferences of the Society of Behavioral Medicine (SBM), an interdisciplinary organization of clinicians, educators, and researchers that investigate the links among behavior, biology, and the environment. Sallis and colleagues found that in 2000, only 5 percent of nutrition or physical activity research abstracts presented at SBM conferences contained environmental or policy content (Sallis et al., 2013). By 2010, that percentage had increased to 17 percent (Sallis et al., 2013). Sallis attributed this increase partly to the establishment of Active Living Research and Healthy Eating Research, two national research programs funded by the Robert Wood Johnson Foundation to stimulate research on the environments, policies, and practices that support physical activity and healthy eating, respectively.

Sallis observed that despite growing evidence of environmental influences on health, health care providers and public health officials are not the ones making decisions about parks or transportation. He argued that changing the built environment requires new partnerships among multiple sectors, including retail food, city planning, urban design, real estate, transportation, architecture, parks and recreation, criminology, economics, law, advocacy, and public health. Many examples of such partnerships exist, he noted, and are described in a number of resources, including a special September 2016 issue of The Lancet devoted to urban design, transport, and health (The Lancet, 2016); Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities (HHS, 2015); and a report of the Community Preventive Services Task Force on combining transportation system interventions with land use and environmental design (Heath et al., 2006). “We need to be thinking about linking our agenda with other agendas to create strength,” Sallis asserted.

Sallis closed by suggesting that increasing awareness of the links among the built environment, physical activity, and obesity has led to many positive developments. But, he said, “we are still building places that we have evidence are going to cause ill health. Many people, if not the majority of people, in the United States are living in places that create ongoing seri-

ous barriers to healthy eating and active living. There is much more to be done.”

ORGANIZATION OF THIS PROCEEDINGS

This summary of the workshop proceedings largely follows the workshop agenda (see Appendix A). Chapter 2 summarizes the first session of the workshop, which provided an overview of the relationships among the built environment, obesity, and health. Chapter 3 contains three case studies from leaders who are changing the built environment at the local, regional, and state levels. Chapter 4 addresses a challenge in using the built environment to advance obesity solutions: making healthy environments equitably available. Finally, Chapter 5 summarizes the last session of the workshop, which featured an open-ended discussion of potential opportunities for action to improve the health of Americans through modifications to the built environment. The acronyms and abbreviations used throughout this proceedings are listed in Appendix B, and biographies of the speakers and facilitators can be found in Appendix C.

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