Pediatric Annals

CME Article 

Childhood Obesity and the Built Environment

Nooshin Razani, MD, MPH; June Tester, MD, MPH

Abstract

It is a September afternoon, and your waiting room is full. You step in to greet Anna, a 38-year-old woman with type 2 diabetes, who brings in her three children for their annual physicals. You have not seen them for about a year. She requests a medication refill for her 3-year-old daughter, Kayla, who has allergic rhinitis. You glance at the chart to note that Kayla’s BMI is now at the 90th percentile. Anna’s middle child, David, is 11 and needs a form filled for the new middle school he starts tomorrow. He also appears overweight. Anna requests a dermatology referral for 15-year-old Erica for a “funny rash” noted on the back of her neck for some time now. The last note in Erica’s chart details an exercise and healthy eating action plan made last year. She missed several follow-up appointments and never came in for her fasting labs.

Abstract

It is a September afternoon, and your waiting room is full. You step in to greet Anna, a 38-year-old woman with type 2 diabetes, who brings in her three children for their annual physicals. You have not seen them for about a year. She requests a medication refill for her 3-year-old daughter, Kayla, who has allergic rhinitis. You glance at the chart to note that Kayla’s BMI is now at the 90th percentile. Anna’s middle child, David, is 11 and needs a form filled for the new middle school he starts tomorrow. He also appears overweight. Anna requests a dermatology referral for 15-year-old Erica for a “funny rash” noted on the back of her neck for some time now. The last note in Erica’s chart details an exercise and healthy eating action plan made last year. She missed several follow-up appointments and never came in for her fasting labs.

Nooshin Razani, MD, MPH, is Attending Physician, Adolescent Medicine Department, Children’s Hospital & Research Center at Oakland, CA. June Tester, MD, MPH, is Co-director, Healthy Hearts Obesity Clinic, Cardiology Department, Children’s Hospital & Research Center at Oakland.

Dr. Razani and Dr. Tester have disclosed no relevant financial relationships.

Address correspondence to: Nooshin Razani, MD MPH, 5400 Telegraph Ave., Oakland, CA 94609; fax 510-428-3170; e-mail: nrazani@mail.cho.org.

It is a September afternoon, and your waiting room is full. You step in to greet Anna, a 38-year-old woman with type 2 diabetes, who brings in her three children for their annual physicals. You have not seen them for about a year. She requests a medication refill for her 3-year-old daughter, Kayla, who has allergic rhinitis. You glance at the chart to note that Kayla’s BMI is now at the 90th percentile. Anna’s middle child, David, is 11 and needs a form filled for the new middle school he starts tomorrow. He also appears overweight. Anna requests a dermatology referral for 15-year-old Erica for a “funny rash” noted on the back of her neck for some time now. The last note in Erica’s chart details an exercise and healthy eating action plan made last year. She missed several follow-up appointments and never came in for her fasting labs.

The scenario is a familiar one to pediatricians. The purpose of the family’s visit appears routine: an allergy medicine refill, school paperwork, and a rash. However, you know that obesity and inactivity are likely core contributors to this family’s problems and need to be addressed. Looking at the long patient list, a packed waiting room, and phone calls to make between patient visits, you wonder whether you can possibly encourage this family to make life altering and healthy choices in the short amount of time you have with them.

There is an ever-growing body of knowledge regarding the increasing prevalence of obesity1 and the negative health outcomes of obesity in children.2 We know that obesity is multi-factorial; that genetic, individual psychosocial factors, family structures, and social norms may influence our patients’ behavior.3 In addition, we are learning more about how to be effective with behavioral interventions. Many of us have studied and tailored anticipatory guidance to our patient’s lives. However, even if we are able to motivate the family to make some behavior changes, our well-intentioned recommendations often are rendered ineffective.

You manage to ask about physical activity and eating habits for the children and learn that Kayla loves playing in the park, David dreams of learning karate, and Erica would love to dance. But, Anna explains definitively, there is no safe park within walking distance, David’s school is on the opposite side of town as the (expensive) karate studio, and it is too dangerous for Erica to be out at night. Currently, Erica and David take a school bus home and spend the afternoon watching television until their mother arrives at 6 or 7 p.m. They skip breakfast and eat lunch at school. Then, Anna usually stops by the local fast food shop on the way home to pick up dinner. Kayla spends much of the day at a daycare center, where there is a small yard (and where she eats her snacks and lunch).

Increasingly, we are becoming aware that access to spaces for physical activity and healthy food is part of the network of factors that influence childhood obesity.4 The “built environment” is the term used to describe the spaces that make up our children’s lives, including the buildings that are their homes, schools, places of recreation, the transportation they use, and the human-constructed outdoor spaces in between.5

In this article, we hope to give pediatricians a sense of how the places our patients live affect their lives. We begin by reviewing what is known about the effect of the built environment on physical activity and food access for children. We also summarize the more limited information correlating the effect of built environment on obesity. As a clinician, you can tell people to change what they eat and how much they exercise, but can you really affect where they live? To this end, we conclude by discussing ways a pediatrician may be able to help their patients navigate their built environment. In addition, we introduce the concept of the “social environment,” another potential resource to help patients navigate their built environment.

The Built Environment and Opportunities for Physical Activity

The American Academy of Pediatrics Sports Medicine and Fitness recommends 60 minutes of physical activity for children a day.6 In the course of a usual day, children have the opportunity to be active either as a byproduct of getting to and from other activities (“incidental activity”) or through purposeful recreation (“recreational activity”).

The extent that a child’s environment gives cause for incidental activity or access to recreational activity can have an effect on their physical activity. For preschool aged children, the built environment often consists of their home and school settings.7 When thinking about Kayla, it is important to consider that she may spend the majority of her life indoors. What is her preschool setting like? Is her indoor environment at home conducive to physical activity, or is it a cell for “screen time?” Is there a front or back yard in either place where she can spend unstructured play time? If so, then it is only a matter of priority to create time for Kayla to have active play.

For school-aged children, such as David, opportunities to walk to school or for active play during school are important factors. Because most children spend about 6 to 7 hours in school a day, school is second only to sleep as the activity in which they spend the most time.8 About half of all American children in 1969 walked to school;9 today, fewer children walk to school, and the percentage is estimated to be less than 15%10 to 17%.11 Parents consistently cite distance to school and traffic danger as the most common barriers to walking to school.11,12

Living far from school was not always the norm. It is, in many ways, a byproduct of the “suburbanization” of residential America. Sprawling design of communities makes for longer distances between destinations. Zoning laws dictate four kinds of land use: residential, industrial, greenspace, and institutional (ie, schools). More sprawling urban communities have less mixing of these types of designs, (or less “land use mix”). As demonstrated in the Figure, (see page 134), the houses and apartments in the sprawling upper section of the diagram are separated by greater distance from other types of destinations, such as schools and shopping malls, than are the older, more traditional neighborhoods.

An Illustration of the Concept of a “sprawled” Neighborhood (upper) and “traditional” Neighborhood. Note that Streets Tend to Connect to Each Other, and Land Use Is Mixed in the Traditional Neighborhood. Figure 1 from “The Traditional Neighborhood Development: How Will Traffic Engineers Respond?”pages 17–18, ITE Journal. September 1989. Copyright 1989. Institute of Transportation Engineers, 1099 14th Street, NW, Suite 300 West, Washington, DC 20005-3438 USA, www.ite.org. Used by Permission.

Figure. An Illustration of the Concept of a “sprawled” Neighborhood (upper) and “traditional” Neighborhood. Note that Streets Tend to Connect to Each Other, and Land Use Is Mixed in the Traditional Neighborhood. Figure 1 from “The Traditional Neighborhood Development: How Will Traffic Engineers Respond?”pages 17–18, ITE Journal. September 1989. Copyright 1989. Institute of Transportation Engineers, 1099 14th Street, NW, Suite 300 West, Washington, DC 20005-3438 USA, www.ite.org. Used by Permission.

In the lower section of the figure, the traditional neighborhood demonstrates a second core concept from urban transportation planning known as “connectivity.” Connectivity is a concept from planning that refers to the network of streets on the ground, and, at the fundamental level, how easy it is to get from point A to point B. A grid with lots of intersections gives a pedestrian or driver many options of navigating the shortest distance.13 In the sprawling part of the diagram, however, you can see that although there are some houses that aren’t all that far from the school, actually getting to the school requires winding all the way out of the enclave of houses to the main road to get to the school. In the sprawling neighborhood, a child who technically lives quite close to school can still find walking to that school prohibitive because of the long route that must be taken and because the routes may involve crossing large streets with heavy traffic. Urban planners and transportation engineers have long shown that traditional (pre-1940s) housing is associated with more residents walking to work.14 A study from the National Health and Nutrition Examination Survery (NHANES) showed that adults living in homes built before 1973 were more likely to walk a mile at least 20 times a month.15

In addition to the “suburbanization” phenomenon, policies regarding school size have contributed to creating distance between where children live and where they go to school. In the 1970s, the Council of Education Facilities Planners International (CEFPI) made recommendations about the minimum acreage on which schools should be sited. According to those guidelines, an elementary school needed to be on at least 10 acres, a middle school had to be on at least 20 acres, and a high school had to be on at least 30 acres.

In addition to this, all types of schools had to have an extra acre for every 100 students.16 These regulations, although made with the intent of creating good learning spaces for students, had a detrimental effect on neighborhood schools, most of which are between 2 and 8 acres. Aging neighborhood schools, which were not only close walking distance for students but which served as anchors within the community as places for programs after school hours, gathering points, and even bomb shelters, were torn down because getting their acreage up to regulation standards would mean eliminating nearby houses.17 States have had “percentage rules” mandating that if the costs of renovating an old school would approach a certain percentage of the cost of building a new school (50% in Virginia and 60% in Minnesota, for example), a new school had to be constructed in order to continue to obtain state funding.16 Because the only sites with sufficient acreage to meet these standards were at the edges of urban areas, it is at these edges that the new schools were born.

In addressing Erica’s concerns, you find out that she is particularly interested in taking an aerobics dance class at an athletics club about 10 miles away. Her mother feels torn, because you have told her that Erica’s rash is acanthosis nigricans, a precursor to diabetes, and so she would love to encourage her daughter’s interest in exercise. But she is concerned about the logistics of how she can get her daughter there.

Living out in the “exurbs,” or a commuter development, has meant that Erica’s parents spend more time commuting in traffic and less time available to drive her to places. One teenager from Northern Virginia summed up the experience of dependence on automobiles caused by remote school sites with the following quote: “If students do any sort of after-school activity, they must drive themselves home, bum rides or wait to be picked up. ... My parents are sick of chauffeuring me, and I am sick of begging rides to go anywhere.”16

What about youth who live in areas that are more compact, built on the pre-1940s scale rather than the sprawling layouts that we see in more modern suburbs and exurbs? Do they experience all the benefits that we might predict of kids living on a compact, walkable, grid designed in an era that preceded our love affair with the automobile? There is an unfortunate paradox here. Many children who live in the heart of our cities have less, and not more, opportunities for physical activity. With the exodus from city to suburban areas, there has been a drop in municipal resources to build or maintain public facilities, such as a recreation center or pool, and less economic pull to draw in private gyms.18,19

Children with low incomes had more consistent associations between weight status and the built environment,20 likely because these lower income youth have fewer options for physical activity and are thus even more dependent on parks or other local amenities.22 Those lowand middle-income youth who are fortunate enough to have access to a safe park do, indeed, have increased physical activity. In a cross-sectional study of 6,680 children in Massachusetts, as an example, children living in low-income areas had less open space, a greater density of fast food restaurants, and higher rates of obesity. This is in contrast to teens living above 300% of the poverty line, whose physical activity patterns seem unrelated to the presence of a safe park. This may occur because the parents of more affluent children can drive them to remote places for recreational activity.

In looking at access to recreational activity, one of four California teens report having no access to a safe park, playground, or open space for physical activity. Additionally, certain populations are particularly at risk for being “park poor.” A geographic survey of Los Angeles showed that although stereotypically, white neighborhoods had approximately 31.8 acres of park space for every 1,000 people, Latino neighborhoods had an even less equitable distribution, with only 0.6 acres for every 1,000 people.21

You decide to brainstorm with Anna regarding ways to help her children be more physically active. You tell her about how there is a recreation center in their neighborhood that offers karate and aerobics classes. It’s a mere 5-minute walk, you estimate. In fact, you have a schedule in your office, and you point out that there is an aerobics class on Mondays at 6 p.m., and there is a discount for new members, which would make this class very affordable. You are excited about your ability to make a concrete recommendation. Then you notice that Anna has a troubled expression on her face. “You know,” she says, “I don’t get home from work until after 6 p.m. I can’t drive Erica, and I don’t want her walking there by herself. Our neighborhood isn’t all that bad, I guess, but these days, you never know what crazies are out there. And did you see that kidnapping on the news the other day? No, I don’t think I’d let Erica walk outside when it’s so close to getting dark at night.”

Teens are theoretically more independent than their younger counterparts, and therefore, should be more able to walk to and from their destinations. However, researchers have found that parental perceptions of safety can limit the ability of their teenage children to perform independent activity.23,24 Parents frequently feel that it is simply not safe to walk outside. There are certainly several different types of “dangers” that can lead someone to feel that a neighborhood is unsafe. In general, these perceived risks to pedestrians and cyclists can be thought of in two categories: risks from other humans (reckless drivers or criminals) or risks from non-human threats in the environment (unattended dogs or poor roadway structure).

Focus groups and interviews with parents frequently reveal that concern about strangers is a primary reason for restricting their children’s free-play activity outdoors.25 Residents of neighborhoods with a high incidence of street crimes make a rational choice to keep their children indoors. Unfortunately, the choice comes at a price because it decreases their child’s opportunities for physical activity. This was corroborated by a longitudinal study in Chicago neighborhoods, which evaluated parental ratings of safety in their neighborhood, as well as third-party ratings of evidence of social disorder based on videotapes in the neighborhood. These researchers showed that the more unsafe a neighborhood was rated, the less physical activity the children had.26

The fear of kidnappings or attacks is so strong among parents that they prevail even when statistics in the neighborhood would show that they need not be so fearful. This fear still prevents children from being outside in their neighborhoods. American culture has been described as having a pervasive “culture of fear,”27 in which we are more obsessed with highly publicized events statistically unlikely to happen to us (such as a kidnapping) than we are with very common risks, such as obesity or heart disease. Americans are more concerned about street crimes now than before, despite the fact that violent crime has been trending downward in the past few decades.28 Evidence has also shown that girls are disproportionately more likely to have a decrease in their physical activity if crime or traffic safety is of concern.7

Fifteen-year-old Erica is on the brink of being eligible for obtaining a driver’s license. This rite of passage has become a near necessity for teen independence in our spread-out American suburban areas. No longer dependent on others to drive her, Erica could finally drive herself to school, to dance class, the movie theater, and beyond. This independence and ability to get around in suburbia comes with a price. Driving carries a tremendous burden of risk. A built environment where teens could walk or bike to their destinations rather than driving would have an effect that goes even beyond the extra calories burned in transit. Even when the destination has nothing to do with exercise (going to the movies is inarguably a sedentary activity), the benefit of that added brisk walk or bicycle ride would be meaningful to her physical activity for the day. But because Erica’s family moved from a more traditional neighborhood with compact design to a suburban development with winding streets and cul-de-sacs, there are fewer destinations near her home that she can walk to. Erica now lives in an environment where exercise is planned and scheduled and doesn’t happen “incidentally” as a part of her daily life.

The Built Environment and Access to Healthy Food

You then turn your attention to David. He has his backpack with him in the office. He’s holding a soda in a cup with a fast food logo, and you can make out two candy bars in the outside mesh pocket of his backpack. His mother points out that she thinks he’s due for his tetanus booster, but otherwise doesn’t feel that there are other concerns. You acknowledge this, and plot his height and weight on his growth chart, noting that his BMI is greater than the 95th percentile. You ask the mother how she feels about the snack foods he gets at school and whether she thinks there is a problem. She isn’t happy about it, but then reasons out loud, “Well, he is a growing boy, and probably just gets hungry at the end of the day.”

In the search for the reasons for obesity in American youth, many policy makers and researchers are appropriately looking at the food environment in the schools. In September 2005, California passed two key pieces of legislation regarding food environment in schools. One establishes strict nutrition standards on all foods sold in K-12 schools, including vending machines, as well as cafeterias.29 The sale of soda was already banned in California elementary and middle schools, but in 2005, California passed a bill that also bans soft drink sales in high schools.30 Although these are important steps, let’s, for a moment, broaden our stance even more and look not just at the food environment in schools but around schools, as well.

When it comes to investigating how junk foods find their way to our children’s hands during and after the school day, the story unfortunately does not occur only on the campus grounds. Many schools have “open lunch” policies, where students are free to leave campus during the lunch period. Children who attend schools with an open lunch policy very frequently eat their lunches at fast food restaurants or convenience stores located near campus.31 A study from Chicago showed that fast food restaurants appear to be clustered around schools. Using spatial analysis, the researchers estimated that there were 3 to 4 times as many fast food restaurants within 1.5 km of schools than would be expected if those fast food restaurants were randomly distributed. Nearly 80% of schools had at least one fast food restaurant within 800 meters.32

Regulations on the nutritional value of what is offered in school are crucial and lie in the domain of legislative policy regarding schools. However, fast food restaurants and sources of junk food in the immediate vicinity of schools (and the lack of zoning policy to restrict this unhealthy food milieu) is an excellent example of how the built environment affects our children’s eating behavior and consequent health.

The Built Environment and Obesity: What Is the Evidence?

The specifics of how to evaluate the effects of the built environment on obesity are currently being reported. A review of the existing literature demonstrates how biases arise, depending on whether the parent or the child gives the information about physical activity and food intake, when actual BMI is measured versus reported weight, and whether the study is cross-sectional or if it is a longitudinal cohort study. Despite these limits in methodology, built environment characteristics, such as limited access to recreational facilities and neighborhood patterns of urban sprawl, correlate to obesity. These relationships differed by gender, age, and socioeconomic status, as discussed in the text above.7 Several large cohort studies on the topic are currently under way, including the National Children’s Study, a prospective study of 100,000 children.3,33

The Role of the Pediatrician

You apologize to Anna, as you must tend to your remaining patients. Before leaving the room, you hand the computer keyboard to Erica and ask her to help her mother by looking for a parent’s group in the neighborhood. You check in on them in between patients and find that Erica has found a discussion board about neighborhood safety and has signed her mother up. Erica wants to post a request for other teens who may be willing to walk to the neighborhood gym with her. Erica’s siblings and mother seem proud of her. In the meantime, you have also remembered that David’s school has an active PTA and suggest that Anna ask about forming a walk-to-school group. Anna looks a bit overwhelmed by the thought of more strains on her over-extended life but is willing to try going to a meeting.

The pressures on parents are large, and time commitments complicated. However, when given the opportunity to connect with each other, parents have often been successful in creating significant changes in their built environments. One particular example has been the Safe Routes to School movement. Traffic safety is the second most frequent concern parents have in allowing their children to walk to school, after distance to school. Many local and state programs across the country have worked toward the goal of increasing the number of children who walk and bike to school by advocating for education and engineering changes to improve traffic safety. Engineering changes that make streets more pedestrian-friendly and slow traffic to make walking less dangerous are effective. An interesting example of such a program is the “Walking School Bus,” which has been implemented in many cities. A “carpool without the car,” adults lead the band of children on their way to school, picking them up along the route. This method addresses parents’ concerns about adult supervision and safety on the way to school.

The state of California has had a Safe Routes to School program, which heavily funded improvements to the street and traffic environments around schools. The program was evaluated by a team of researchers at the University of California at Irvine, who found a significant increase in walking/biking to school among children who used the Safe Routes to School routes to go to school.34

In July 2005, Congress approved a bipartisan $612 million bill for a federal Safe Routes to School program to be given to the State Department of Transportation in each of the 50 states. These funds go toward infrastructure improvements (building more sidewalks, speed reduction interventions, crossings near schools) as well as for public education campaigns, such as “Walk to School Days,” to increase awareness in communities. The program was renewed in 2009 with even more allotted funds.

Things are changing. In response to sentiment that mega-schools are actually detrimental to students,35 the Council of Education Facilities Planners International (CEFPI) has rewritten its recommendations about school size. They have produced several new publications, such as “Schools for Successful Communities: An Element of Smart Growth (2004),” and are now promoting interest in revitalizing historic neighborhood schools. Some states are following suit; for example, South Carolina eliminated minimum acreage requirements for schools in 2003,10 and Florida is now mandating smaller schools, limiting high schools built after 2003 to 900 students.36

However, it is important to note that these changes are by no means uniform; CEFPI recommendations are mere guidelines, and many, but not all, states have policies regarding minimum acreage and “percentage rules” relating to choosing renovation or new construction.

Any parent or child advocate should familiarize himself or herself with the state policies that control how children’s schools are constructed. For a pediatrician, knowledge of local policy is important as (s)he inquires about whether his or her patient gets physical activity, such as walking on a regular basis.

The Social Environment

Although the physical environment is important, the social environment is also important. In a multisite study of 650 children in a variety of urban settings in United States (ranging from Los Angeles County to Texas), researchers observed neighborhoods for physical environment and social environment characteristics. The latter included markers of collective efficacy (how empowered the community members feel that they can change their circumstances), “collective socialization of children” (whether or not people help each other out if children are in trouble or misbehaving), “social exchange,” “social contact,” and perceived safety. In this study, physical activity was correlated not only with certain built environment characteristics, but also with supportive “social environments.”37

Conclusions

Pediatricians and all practitioners interacting with children have a distinct role in helping patients find access to physical activity and healthy food in their environments. If we are unable to identify resources in our communities, we can attempt to help connect them to social supports in their neighborhoods.

References

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CME Educational Objectives

  1. Review the current literature on the effect of the built environment on physical activity and food access for children.

  2. Recognize the correlation between the built environment and obesity, drawing attention to the limited data currently available.

  3. Discuss strategies practicing medical professionals can employ to help families navigate their local built environment.

Authors

Nooshin Razani, MD, MPH, is Attending Physician, Adolescent Medicine Department, Children’s Hospital & Research Center at Oakland, CA. June Tester, MD, MPH, is Co-director, Healthy Hearts Obesity Clinic, Cardiology Department, Children’s Hospital & Research Center at Oakland.

Dr. Razani and Dr. Tester have disclosed no relevant financial relationships.

Address correspondence to: Nooshin Razani, MD MPH, 5400 Telegraph Ave., Oakland, CA 94609; fax 510-428-3170; e-mail: .nrazani@mail.cho.org

10.3928/00904481-20100223-04

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