Download 2 - Canadian Public Health Association

Healthy Cities – Diabetes Prevention
Policy changes in the urban built
environment: implications for
diabetes prevention
Gillian Booth
Li Ka Shing Knowledge Institute,
St. Michael’s Hospital
Institute for Clinical Evaluative Sciences
The ‘Built Environment’
Our physical surroundings, including
buildings, parks, schools, road systems, and
other infrastructure that we encounter in our
daily lives
WHO estimates 350 million people worldwide with diabetes
Rapid shifts in urbanization
–Rural to urban migration
–Fewer opportunities for physical activity and healthy eating
MacLeans January 8, 2013
More
opportunities
for sedentary
choices
Greater reliance
on automobiles
More time spent in cars -> higher rates of obesity
Frank LD et al Am J Prev Med 2004
The built environment as a
potential target for intervention
Features of Walkable Neighbourhoods
• More compact/dense
• Grid-like street pattern
(shorter blocks)
• Mixed land use
• Destinations within
walking distance
More walkable neighbourhoods
more walking
Suburban design discourages walking
and increases reliance on cars
• Large
lot sizes (more
sprawl)
• Less connected
streets (longer blocks)
• Purely residential
zoning
• Few walkable
destinations
Less walkable neighbourhoods less walking,
less physical activity and more obesity
Theoretical link between urban built
environment and type 2 diabetes
Built
Environment
Walkability,
parks,
recreational
spaces
Walking,
bicycling,
other
activities
Weight
gain,
overwt &
obesity
Type 2
Diabetes
Limitations of prior studies
• Unable to prove causal relationship
• Unable to randomize people to live in one
community over another
Green Space
People living in neighborhoods with
more green and open spaces had
13% lower rates of Type 2 diabetes.
Astell-Burt et al., Diabetes Care 2014
Perceived
supportive
environment for
physical activity
• 17% less likely to be
insulin resistant
• 39% less likely to
develop type 2
diabetes
Auchincloss et al., Arch Intern Med 2009
Does area walkability
predict the development of
diabetes?
30 - 50,000
50 - 75,000
75 - 100,000
100- 150,000
150- 375,000
Neighbourhood Environments and Resources for Healthy Living: A Focus on Diabetes in Toronto, 2007
Our walkability index
Sprawling vs. compact
Neighbourhoods
Zoning differences
Population density*
Residential density*
Land use mix
Walkable destinations*
Lay out of streets
(short vs. long blocks; grid-like
vs. curvilinear or cul-de-sacs)
Street connectivity*
Defining neighbourhood
exposures
Transportation behaviours and obesity
rates in Toronto by walkability quintile
Characteristic (%)
Q5:Q1 ratio
(highest to lowest
walkability score)
Walk or bicycle to work
3.09
Public transit to work
1.72
Drive to work
0.57
Obesity*
0.75
*CCHS population, age 30-64 yrs; Transportation Tomorrow Survey,
Glazier et al., Plos One 2014
p < .001 for all
Rate Ratio of Lowest vs. Highest scores (Q1:Q5)
Population density
Residential density
Walkable destinations
Street connectivity
Density, Destinations and Transportation Choices
(Glazier et al., 2014)
Walkable Destinations: Density and Destinations
Spatial Concordance Between Residential Density and Availability of Walkable
Destinations. (Glazier et al., 2014)
Are individuals living in more walkable
areas at lower risk of developing
diabetes?
Overview of methods
Neighbourhood
level data
Walkability
+
Provincial
health records
All residents living in
a given area
Postal code of residence
Follow whole populations over time
Walkability and Diabetes Incidence
Study population
= 1,658,027 adults age 30-64 yrs, living in Toronto,
free of diabetes at baseline
April 1, 2005
March 31, 2010
Diabetes*
* based on validated algorithm using records from hospitalizations and physician service claims
Booth et al., Diabetes Care, 2013
Study population
N=1,658,027
212,882
Recent immigrants
1,445,145
Long term residents
Booth et al., Diabetes Care, 2013
Young and middle-aged men followed for 5 years
Booth et al., Diabetes Care, 2013
Limitations
• To what extent does ‘self-selection’ (individual
preference) account for findings
• Would changes in community design promote
physical activity, reduce BMI and decrease the
likelihood of developing diabetes?
Are individuals living in more walkable
areas at lower risk of developing
diabetes after accounting for ethnicity,
income and obesity-related health
conditions?
How do we get multiple sectors and
agencies involved in translating evidence
into planning and practice?
Potential policy interventions
• Changing standards for new developments
• Restructuring of existing communities
• Zoning changes, tax incentives or other initiatives to support
healthy food retailers or other services to move into high
need areas
• Expanding transit options, adding walking paths, cycling
infrastructure
• Target neighbourhoods with unsupportive environments for
diabetes prevention initiatives
Knowledge users as disseminators
Integrated KT Event: Multi-Sectoral Engagement
The objectives of the event were:
1. Disseminate research findings to key stakeholders
2. Engage key stakeholders to explore potential
applications
3. Provide a forum for sharing success stories and
barriers to achieving changes in the built environment
4. Establish partnerships with researchers, planning
and public health
Involving Municipalities, Provincial Gov’t &
Relevant Agencies
Regions/Municipalities
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Toronto
Ottawa
London
Peel
Hamilton
Halton
Durham
York
• Public Health, Planning
and Transportation
Non-governmental
organizations
• Canadian Diabetes
Association
• Canadian Partnership
Against Cancer
• Ontario Professional
Planners Institute
• Ontario Public Health
Association
• Heart & Stroke
Foundation
• Canadian Institute for
Health Research
Government
• Public Health Agency of
Canada
• Ministry of Health and
Long-Term Care
• Ministry of
Infrastructure
• Ministry of Municipal
Affairs and Housing
• Public Health Ontario
Targeted and
Impactful
Messaging
Implementation focus on
the “how”
Common
Measures
and Tools
Emerging Themes
from Research on the
Built Environment
Importance
of Public and
Private Sector
Advocacy
Intersectoral
collaboration
within and
between
Levels of
Government
Tailored
research for
informed
policymaking
Research priorities
• How effective are current or upcoming
policy initiatives?
– Ability to study natural experiments
– Need to build in evaluation of ongoing
initiatives
• Best return on investments
– Economic analyses?
Next steps to support policy and planning related to the built environment
Summary
• Providing more opportunities to be physically active
is a key step the battle against obesity and diabetes
• Interventions targeting the built environment that
encourage physical activity may have substantial
health benefits for the population
• Challenges in translating research findings into
policy and planning initiatives will require
collaboration across sectors and levels of
government
Built Environment and Diabetes
Co-Investigators
Project Team
Collaborators
Jim Dunn
Marisa Creatore
Jack Tu, ICES
Rick Glazier
Public Health Ontario
Doug Manuel
Medical Geographers: Peter Gozdyra
& Jonathan Weyman
Flora Matheson
Students/Fellows:
Toronto Public Health
Rahim Moineddin
Ghazal Fazli
Laura Rosella
Jane Polsky
Nancy Ross
Vered Kaufman-Shriqui
Sara Guilcher
Maria Chiu
Region of Peel