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AN INTRODUCTION TO PRIMARY DATA
COLLECTION AND ASSESSMENT TOOLS AND
METHODOLOGIES FOR UNDERSTANDING
LOCAL FOOD ENVIRONMENT...
Outline
 Background on the Built Environment and Health
 Measures of the Physical Activity Environment
 Neighborhood En...
The Built Environment
 Land-Use Patterns
 Spatial distribution of human activities
 Transportation Systems
 Physical i...
Low Density, Low Connectivity,
Low Land Use Mix
High Density, High Connectivity,
High Land Use Mix
Background: The Built E...
The Built Environment and Health
 Air Quality
 Motor Vehicle Crashes and Motor Vehicle-
Pedestrian Collisions
 Mental H...
The Common Roots of Urban Planning and Public Health
 Industrial Revolution and
Congestion in Cities
 Infectious disease...
The Common Roots of Urban Planning and Public Health
 Public Health Responses
 1842: Report on the Sanitary
Conditions o...
Divergence of Public Health and Urban Planning
 Germ Theory
 Focus on single-agent causes of specific diseases
 Economi...
Modern Urban Form: Sprawl
Modern Urban Form: Sprawl
 Development outpaces population growth
 Low density
 Rigidly separated homes, shops, and
wor...
Urban Form and Transportation
 Sprawling areas
exhibit
 Higher rates of
vehicle ownership
 More vehicle-miles
traveled ...
Air Quality
 Urban form determines transportation
patterns
 Transportation patterns determine vehicle
emissions
 Vehicl...
Motor Vehicle Crashes and Motor Vehicle-
Pedestrian Collisions
 Urban form is associated with
VMTs
 VMTs increase time a...
Motor Vehicle Crashes and Motor Vehicle-
Pedestrian Collisions
 NHTSA statistics
 Less sprawling cities
 New York (2.30...
Mental Health
 Urban form is associated with VMTs
 Higher VMTs are associated with higher
levels of stress
 Known stres...
Mental Health
 Depression
 Limits on physical activity may deny
a treatment for depression
 Low density leads to social...
Water Quantity and Quality
 Water quality
 Biological pollutants
 Hepatitis A or E
 Coxsackie viruses, Adenoviruses,
a...
Water Quantity and Quality
 Decreasing density, proximity, and connectivity require
more impervious paved surface per cap...
Disparities
 Low SES populations
 More likely to
 rely on walking and public transit to commute
 live near high-speed ...
Disparities
 Older and Disabled
Persons
 Limited mobility
 Reliance on
automobiles
 Fewer transit options
 Social iso...
Physical Activity
 Obesity and overweight
 Type 2 diabetes mellitus,
gallbladder disease, coronary heart
disease, high b...
Physical Activity
 Three factors of urban form that may determine
physical activity
 Transportation systems connect plac...
Physical Activity
 Sprawling communities associated with
 Lower rates of physical activity
 Higher body mass index (BMI...
Diet
 The presence or density of food retailers and restaurants is
thought to be related to diet
 Supermarkets provide a...
Summary
 Public health historically linked to urban planning
 The built environment is associated with
 Air pollution
...
Significance
 The health behaviors and health outcomes
discussed are major contributors to
morbidity and mortality in the...
Physical
activity
Obesity
Supermarkets
and grocery
stores
Convenience
stores
Fast-food
restaurants
Sit-down
restaurants
Ac...
Measuring the
Built
Environment
Scale
Objective v
Subjective
Factual v
Perception
Question of
Interest
Duany and Plater-Zy...
I S S U E S , M E A S U R E S , A N D E X A M P L E S
The Physical Activity
Environment
Physical Activity Environment: Issues to Consider
 Scale
 County, city, neighborhood, street?
 What to Measure
 Walkin...
Physical Activity Environment Measures
 Self-Report
 Questionnaires about perceptions of built
environment
 Neighborhoo...
Physical Activity Environment Measures
 Geographic Information System (GIS)-based
 Software system linking multiple data...
Physical Activity Environment Measures
 Observations or Audits
 Reliable and valid measures of the ground-level built en...
E X A M P L E 1
S E L F - R E P O R T
Neighborhood Environment
Walkability Survey-Abbreviated
Neighborhood Environment Walkability Survey-Abbreviated
 The NEWS-A assesses perceived residential density,
land use mix ...
E X A M P L E 2
G I S - B A S E D
GIS-Based Assessment of the
Physical Activity Environment for
Research
Exposure Assessment: Residence-Level Built Environment
 Residential density
 Census tract density
from US Census
data
 ...
Street Network Buffers
 800m road network buffers
around geocoded home
addresses, excluding
interstates and ramps
 800m ...
Street Network Buffers
 Polygons created
radiating from residence
800m via local road
network with 50m on
each side of th...
Residential Density
 Area weighted sum for
network buffers based
on intersecting census
tracts from US 2000
Census data
Residential Density
 Area weighted sum for
network buffers based
on intersecting census
tracts from US 2000
Census data
Land Use Mix
 Location Count:
Counts of businesses
within 800m network
buffers based on stores,
facilities, and services
...
Land Use Mix
 Location Count:
Counts of businesses
within 800m network
buffers based on stores,
facilities, and services
...
Street Connectivity
 Intersection Count:
Number of 3-way or
greater intersections
per square km within
each network buffe...
Street Connectivity
 Intersection Count:
Number of 3-way or
greater intersections
per square km within
each network buffe...
E X A M P L E 3
G I S - B A S E D
Walk Score
Walk Score
 http://www.walkscore.com/
 The “Street Smart” Walk Score algorithm is based on
walking distances from an add...
E X A M P L E 4
O B S E R V A T I O N O R A U D I T
Irvine Minnesota Inventory
Irvine Minnesota Inventory
 Understanding the impact of the built environment on
physical activity levels requires reliab...
Irvine Minnesota Inventory
 The inventory includes both a paper version and a
version in Microsoft Access, to allow data ...
Irvine Minnesota Inventory
 https://webfiles.uci.edu/kday/public/Irvine_MN_I
nventory.pdf
 Link with full information:
h...
Interested in Learning More?
 Brownson RC, Hoehner CM, Day K, Forsyth A, Sallis
JF. Measuring the built environment for p...
I S S U E S , M E A S U R E S , A N D E X A M P L E S
The Food Environment
Food Environment: Issues to Consider
 Scale
 Community Nutrition Environments
 Type and location of food outlets
 Acce...
Food Environment Measures
 Self-report
 Reports: How far to the nearest store?
 Perceptions: How easy is it to find fre...
Food Environment Measures
 Observation/Audit
 Nutrition Environment Measures Survey for Restaurants
and Stores (NEMS-R, ...
E X A M P L E 5
G I S - B A S E D
Food Environment Atlas
Food Environment Atlas
 http://www.ers.usda.gov/foodatlas/atlas/
E X A M P L E 6
A U D I T
NEMS-R and NEMS-S
NEMS-R and NEMS-S
 http://www.med.upenn.edu/nems/
 NEMS-R:
http://www.med.upenn.edu/nems/docs/NEMS_R_Detailed.pdf
 NEMS...
Interested in Learning More?
 Lytle LA. Measuring the food environment: state of
the science. Am J Prev Med. 2009 Apr;36(...
Other Relevant Measures
 Parks
 Environmental Assessment of Public Recreation Spaces
 http://www.activelivingresearch.o...
Thank You!
 Any questions? Feel free to email me at:
pjames@mapc.org
References
 Babyak M., Blumenthal J.A., Herman S., Khatri P., Doraiswamy M., Moore K., Craighead
W.E., Baldewicz T.T., an...
References
 Ewing R., Schmid T., Killingsworth R., Zlot A., and Raudenbush S. 2003b. Relationship
between urban sprawl an...
References
 Giles-Corti B., Macintyre S., Clarkson J. P., Pikora T., and Donovan R. J. 2003.
Environmental and lifestyle ...
References
 Lucy W. H. 2003. Mortality risk associated with leaving home: recognizing the relevance
of the built environm...
References
 Rathbone D.B., and Huckabee J.C. 1999. Controlling road rage: a literature review and
pilot study. Washington...
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Data Day 2012_James_Accessing Health Risks and Using Health Data

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Data Day 2012_James_Accessing Health Risks and Using Health Data

  1. 1. AN INTRODUCTION TO PRIMARY DATA COLLECTION AND ASSESSMENT TOOLS AND METHODOLOGIES FOR UNDERSTANDING LOCAL FOOD ENVIRONMENT, WA LK ABILITY A ND MOR E PETER JAMES PUBLIC HEALTH SPECIALIST METROPOLITAN AREA PLANNING COUNCIL JANUARY 27, 2012 Accessing and Using Health Data about Your Neighborhood
  2. 2. Outline  Background on the Built Environment and Health  Measures of the Physical Activity Environment  Neighborhood Environment Walkability Survey Example  My Research Example  Walk Score Example  Irvine Minnesota Inventory Example  Measures of the Food Environment  Food Atlas Example  NEMS-R and NEMS-S Example  Other Relevant Measures
  3. 3. The Built Environment  Land-Use Patterns  Spatial distribution of human activities  Transportation Systems  Physical infrastructure and services that provide the spatial links or connectivity among activities  Design Features  Aesthetic, physical, and functional qualities of the built environment, such as the design of buildings and streetscapes, and relates to both land use patterns and the transportation system
  4. 4. Low Density, Low Connectivity, Low Land Use Mix High Density, High Connectivity, High Land Use Mix Background: The Built Environment and Health
  5. 5. The Built Environment and Health  Air Quality  Motor Vehicle Crashes and Motor Vehicle- Pedestrian Collisions  Mental Health  Water Quantity and Quality  Disparities  Physical Activity  Diet
  6. 6. The Common Roots of Urban Planning and Public Health  Industrial Revolution and Congestion in Cities  Infectious disease  Cholera, typhoid, yellow fever, smallpox, and tuberculosis  Deplorable housing conditions  Poor ventilation  Polluted waterways  Toxic industries in close proximity to residences
  7. 7. The Common Roots of Urban Planning and Public Health  Public Health Responses  1842: Report on the Sanitary Conditions of the Laboring Population of Great Britain  1850: Report of the Sanitary Commission of Massachusetts  1916: Zoning laws in New York City  1924: Standard Zoning Enabling Act Lemuel Shattuck
  8. 8. Divergence of Public Health and Urban Planning  Germ Theory  Focus on single-agent causes of specific diseases  Economics  Investment in new communities  Transportation  Investment in the automobile  Dismantling of transit  Federal Policy  Federal Housing Administration  Veterans Affairs Mortgage Program
  9. 9. Modern Urban Form: Sprawl
  10. 10. Modern Urban Form: Sprawl  Development outpaces population growth  Low density  Rigidly separated homes, shops, and workplaces  Roads marked by large blocks and poor access  Lack of well-defined activity centers, such as downtowns  Lack of transportation choices  Relative uniformity of housing options
  11. 11. Urban Form and Transportation  Sprawling areas exhibit  Higher rates of vehicle ownership  More vehicle-miles traveled (VMTs) per person  Lower percentages of commuters taking transit or walking to work
  12. 12. Air Quality  Urban form determines transportation patterns  Transportation patterns determine vehicle emissions  Vehicle emissions are associated with  Respiratory disease  Cardiovascular disease  Cancer  Reproductive outcomes  Premature mortality
  13. 13. Motor Vehicle Crashes and Motor Vehicle- Pedestrian Collisions  Urban form is associated with VMTs  VMTs increase time at risk to the hazards of motor vehicle travel  Urban form can dictate vehicle speeds  Long commutes can lead to fatigue and the increased risk of a crash
  14. 14. Motor Vehicle Crashes and Motor Vehicle- Pedestrian Collisions  NHTSA statistics  Less sprawling cities  New York (2.30 fatalities per 100,000 population)  San Francisco (2.45 fatalities per 100,000 population)  Portland (3.21 fatalities per 100,000 population)  More sprawling cities  Houston (10.08 fatalities per 100,000 population)  Atlanta (12.72 fatalities per 100,000 population)  Tampa (16.15 fatalities per 100,000 population)  Exceptions to this rule  Los Angeles (5.79 fatalities per 100,000 population)  Detroit (10.93 fatalities per 100,000 population)
  15. 15. Mental Health  Urban form is associated with VMTs  Higher VMTs are associated with higher levels of stress  Known stress responses due to driving and commuting  Chronic stress from driving  Cardiovascular disease  Musculoskeletal symptoms
  16. 16. Mental Health  Depression  Limits on physical activity may deny a treatment for depression  Low density leads to social isolation, which leads to depression  Monotony and aesthetic qualities of sprawl may be root of depression  Road rage  Events in which an angry or impatient driver tries to kill or injure another driver after a traffic dispute  Risk factors are traffic volume and traffic distance
  17. 17. Water Quantity and Quality  Water quality  Biological pollutants  Hepatitis A or E  Coxsackie viruses, Adenoviruses, and Norwalk viruses  Pathogenic bacteria Helicobacter or Legionella.  Parasites Cryptosporidium and Giardia  Chemical pollutants  Pesticides, metals, nitrates, radionuclides, and organic chemicals  Disinfection byproducts, such as iodinated trihalomethanes
  18. 18. Water Quantity and Quality  Decreasing density, proximity, and connectivity require more impervious paved surface per capita  Decreases the ability of rainfall to recharge groundwater aquifers  High velocity runoff increases erosion and speeds the transfer of pollutants into the water supply  Storm surges overload sewage treatment plants and discharge excess untreated water directly into adjacent bodies of water, leading to bacterial contamination  Modeling has shown that higher density development reduces peak flows and total runoff volume  Higher rates of motor vehicle use leads to higher levels of pollutants in runoff
  19. 19. Disparities  Low SES populations  More likely to  rely on walking and public transit to commute  live near high-speed traffic areas with fewer clearly marked and safe crossing routes  Pedestrian fatalities  Atlanta pedestrian fatality rates during 1994-1998: 9.74 for Hispanics, 3.85 for African Americans, and 1.64 for Whites  Hispanics: 8% of the population of the Virginia suburbs of Washington, DC; 21% of pedestrian fatalities
  20. 20. Disparities  Older and Disabled Persons  Limited mobility  Reliance on automobiles  Fewer transit options  Social isolation  cognitive decline
  21. 21. Physical Activity  Obesity and overweight  Type 2 diabetes mellitus, gallbladder disease, coronary heart disease, high blood cholesterol level, high blood pressure, osteoarthritis, sleep apnea, stroke, liver disease, musculoskeletal disease, reproductive function, some forms of cancer, and mortality  Sedentary lifestyle  Depression, hypertension, type 2 diabetes mellitus, colon cancer, osteoarthritis, osteoporosis, coronary heart disease, and all- cause mortality
  22. 22. Physical Activity  Three factors of urban form that may determine physical activity  Transportation systems connect places and determine the feasibility of using different modes of transport  Land use patterns determine the proximity of destinations and thereby the feasibility of walking or cycling  Urban design characteristics alter individual perception of whether the environment is desirable or inviting for physical activity
  23. 23. Physical Activity  Sprawling communities associated with  Lower rates of physical activity  Higher body mass index (BMI)  Higher prevalence of hypertension  Overweight and obesity associated with  Streets with no sidewalks or sidewalks on one side only  Lower residential density  Lower land-use mix  Lower street connectivity
  24. 24. Diet  The presence or density of food retailers and restaurants is thought to be related to diet  Supermarkets provide a variety of affordable healthy foods, such as fresh fruits and vegetables and whole grains  Convenience stores supply highly processed foods rather than fresh foods  Fast food outlets offer large portion sizes and energy-dense foods  Growing literature shows diet correlated with the presence or density of food retailers and restaurants  Density of supermarkets associated with higher fruit and vegetable consumption and lower obesity prevalence
  25. 25. Summary  Public health historically linked to urban planning  The built environment is associated with  Air pollution  Water quality and quantity  Motor vehicle crashes  Pedestrian injuries and fatalities  Mental health  Health disparities  Physical activity  Diet
  26. 26. Significance  The health behaviors and health outcomes discussed are major contributors to morbidity and mortality in the US  The built environment is a ubiquitous and modifiable exposure  Built environment studies generally have small sample sizes, cover small geographic ranges, and are cross-sectional
  27. 27. Physical activity Obesity Supermarkets and grocery stores Convenience stores Fast-food restaurants Sit-down restaurants Access to physical activity resources Access, density, and diversity of destinations Residential or population density Street connectivity Access / density food retail Access / density food service Physical activity environment Food environment * Food retail and food service facilities could be also be physical activity destinations. Dietary intake Conceptual model for the effects of the built environment on physical activity and obesity Disease / Mortality
  28. 28. Measuring the Built Environment Scale Objective v Subjective Factual v Perception Question of Interest Duany and Plater-Zyberk. 1989. ITE Journal. 59:17- 18.
  29. 29. I S S U E S , M E A S U R E S , A N D E X A M P L E S The Physical Activity Environment
  30. 30. Physical Activity Environment: Issues to Consider  Scale  County, city, neighborhood, street?  What to Measure  Walking destinations  Connectivity  Micro-scale factors  Walkability?
  31. 31. Physical Activity Environment Measures  Self-Report  Questionnaires about perceptions of built environment  Neighborhood Environment Walkability Scale Example
  32. 32. Physical Activity Environment Measures  Geographic Information System (GIS)-based  Software system linking multiple data sources to place  County Sprawl Index  http://www.smartgrowthamerica.org/documents/MeasuringSpr awlTechnical.pdf  Walkability Index from Frank et al. LUM, Retail Floor Area Ratio, Intersection Density, Residential Density  Primary Research Example  Walk Score Example
  33. 33. Physical Activity Environment Measures  Observations or Audits  Reliable and valid measures of the ground-level built environment  Require clear definitions and observer training  Agreement between observers indicates quality  SPACES (Systematic Pedestrian and Cycling Environment Scan instrument  One of the first audits of the built environment for physical activity  Am J Prev Med 2002  http://sydney.edu.au/medicine/public- health/cpah/research/spaces.php  BRAT-DO (Bedimo-Rung Assessment Tools-Direct Observation)  Focus on parks  Irvine Minnesota Inventory Example
  34. 34. E X A M P L E 1 S E L F - R E P O R T Neighborhood Environment Walkability Survey-Abbreviated
  35. 35. Neighborhood Environment Walkability Survey-Abbreviated  The NEWS-A assesses perceived residential density, land use mix (including both indices of proximity and accessibility), street connectivity, infrastructure for walking/cycling, neighborhood aesthetics, and traffic and crime safety  http://www.activelivingresearch.org/files/NEWS_ Abbreviated.pdf
  36. 36. E X A M P L E 2 G I S - B A S E D GIS-Based Assessment of the Physical Activity Environment for Research
  37. 37. Exposure Assessment: Residence-Level Built Environment  Residential density  Census tract density from US Census data  Land use mix  Location density from InfoUSA  Street connectivity  Intersection density from StreetMap USA
  38. 38. Street Network Buffers  800m road network buffers around geocoded home addresses, excluding interstates and ramps  800m is the upper limit of what individuals are willing to walk, based on urban planning literature  Non-interstate roads are generally walkable; however, we did not specifically measure micro- environment features, such as sidewalk availability, crosswalks, etc.
  39. 39. Street Network Buffers  Polygons created radiating from residence 800m via local road network with 50m on each side of the road  Estimates of the area that is 800m walking distance from each residence via the local road network
  40. 40. Residential Density  Area weighted sum for network buffers based on intersecting census tracts from US 2000 Census data
  41. 41. Residential Density  Area weighted sum for network buffers based on intersecting census tracts from US 2000 Census data
  42. 42. Land Use Mix  Location Count: Counts of businesses within 800m network buffers based on stores, facilities, and services from 2009 InfoUSA spatial database on businesses, which include grocery stores, restaurants, banks, etc.
  43. 43. Land Use Mix  Location Count: Counts of businesses within 800m network buffers based on stores, facilities, and services from 2009 InfoUSA spatial database on businesses, which include grocery stores, restaurants, banks, etc.
  44. 44. Street Connectivity  Intersection Count: Number of 3-way or greater intersections per square km within each network buffer  Interstates and ramps will be excluded
  45. 45. Street Connectivity  Intersection Count: Number of 3-way or greater intersections per square km within each network buffer  Interstates and ramps will be excluded
  46. 46. E X A M P L E 3 G I S - B A S E D Walk Score
  47. 47. Walk Score  http://www.walkscore.com/  The “Street Smart” Walk Score algorithm is based on walking distances from an address to a diverse set of nearby amenities  Certain categories are weighted more heavily than others to reflect destinations associated with more walking trips  In addition, road connectivity metrics such as intersection density and average block length are factored into the score  Walk Score uses a variety of data sources such as Open Street Map, local business listings, and public data sources such as parks and schools
  48. 48. E X A M P L E 4 O B S E R V A T I O N O R A U D I T Irvine Minnesota Inventory
  49. 49. Irvine Minnesota Inventory  Understanding the impact of the built environment on physical activity levels requires reliable methods to measure potentially relevant built environment features  The Irvine Minnesota Inventory was designed to measure a wide range of built environment features that are potentially linked to active living, especially walking  The Irvine Minnesota inventory includes 160 items, which cover four domains: accessibility (62 items), pleasurability (56 items), perceived safety from traffic (31 items), and perceived safety from crime (15 items)
  50. 50. Irvine Minnesota Inventory  The inventory includes both a paper version and a version in Microsoft Access, to allow data to be input into the computer directly  The items in the inventory were tested for inter-rater reliability in both southern California and the Minneapolis - St. Paul metropolitan area  Inter-rater reliability was high, with 77 percent of the items attaining 80% agreement or better in both southern California and Minnesota reliability tests
  51. 51. Irvine Minnesota Inventory  https://webfiles.uci.edu/kday/public/Irvine_MN_I nventory.pdf  Link with full information: https://webfiles.uci.edu/kday/public/index.html
  52. 52. Interested in Learning More?  Brownson RC, Hoehner CM, Day K, Forsyth A, Sallis JF. Measuring the built environment for physical activity: state of the science. Am J Prev Med. 2009 Apr;36(4 Suppl):S99-123.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2 844244/?tool=pubmed
  53. 53. I S S U E S , M E A S U R E S , A N D E X A M P L E S The Food Environment
  54. 54. Food Environment: Issues to Consider  Scale  Community Nutrition Environments  Type and location of food outlets  Accessibility (e.g., hours)  Consumer Nutrition Environment  Availability of healthy food choices  Pricing, promotion, placement  Information availability  Relevant Measure  Grocery store v. Fast food  Proximity to closest v. Density  Not covered here: School or Home Nutrition Environment?
  55. 55. Food Environment Measures  Self-report  Reports: How far to the nearest store?  Perceptions: How easy is it to find fresh fruits or vegetables?  GIS-Based  Food Environment Atlas Example
  56. 56. Food Environment Measures  Observation/Audit  Nutrition Environment Measures Survey for Restaurants and Stores (NEMS-R, NEMS-S ) Example  Combinations of Both  Block JP, Christakis NA, O'Malley AJ, Subramanian SV. Proximity to food establishments and body mass index in the Framingham Heart Study offspring cohort over 30 years. Am J Epidemiol. 2011 Nov 15;174(10):1108-14.
  57. 57. E X A M P L E 5 G I S - B A S E D Food Environment Atlas
  58. 58. Food Environment Atlas  http://www.ers.usda.gov/foodatlas/atlas/
  59. 59. E X A M P L E 6 A U D I T NEMS-R and NEMS-S
  60. 60. NEMS-R and NEMS-S  http://www.med.upenn.edu/nems/  NEMS-R: http://www.med.upenn.edu/nems/docs/NEMS_R_Detailed.pdf  NEMS-S: http://www.med.upenn.edu/nems/docs/NEMS_S_Detailed.pdf
  61. 61. Interested in Learning More?  Lytle LA. Measuring the food environment: state of the science. Am J Prev Med. 2009 Apr;36(4 Suppl):S134-44.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2 716804/
  62. 62. Other Relevant Measures  Parks  Environmental Assessment of Public Recreation Spaces  http://www.activelivingresearch.org/node/10651  Paths  Path Environmental Audit Tool  http://www.activelivingresearch.org/files/PEAT_MANUAL.doc  Neighborhood Safety Audits  Toronto Safety Checklist  http://www.toronto.ca/safetyaudits/pdf/scarb_safety_checklist. pdf
  63. 63. Thank You!  Any questions? Feel free to email me at: pjames@mapc.org
  64. 64. References  Babyak M., Blumenthal J.A., Herman S., Khatri P., Doraiswamy M., Moore K., Craighead W.E., Baldewicz T.T., and Krishnan K.R. 2000. Exercise treatment for major depression: Maintenance of therapeutic benefit at 10 months. Psychosomatic Medicine 62 (5):633-38.  Bassuk S. S., Glass T. A., and Berkman L. F. 1999. Social disengagement and incident cognitive decline in community-dwelling elderly persons. Ann Intern Med 131 (3):165-73.  Bellet S, Roman L., and Kostis J. 1969. The effects of automobile driving on catecholamine and adrenocortical excretion. American Journal of Cardiology 24:365-68.  CDC. Healthy Places Terminology - Designing and Building Healthy Places 2007 [cited. Available from http://0- www.cdc.gov.mill1.sjlibrary.org/healthyplaces/terminology.htm.  Cervero R., and Kockelman K. 1997. Travel Demand and the 3Ds: Density, Diversity, and Design. Transportation Research D 2 (3):199-219.  Champion L. 1990. The relationship between social vulnerability and the occurrence of severely threatening life events. Psychological Medicine 20 (1):157-61.  Ewing R., Brownson R. C., and Berrigan D. 2006. Relationship between urban sprawl and weight of United States youth. Am J Prev Med 31 (6):464-74.  Ewing R., Pendall R., and Chen D. 2002. Measuring Sprawl and Its Impact. Washington, DC: Smart Growth America.  Ewing R., Schieber R. A., and Zegeer C. V. 2003a. Urban sprawl as a risk factor in motor vehicle occupant and pedestrian fatalities. Am J Public Health 93 (9):1541-5.
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