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The Healthy Communities Agenda:
How We Can Work Together

Congress for the New Urbanism
June 13, 2009

Dee Merriam, FASLA
Community Planner
National Center for Environmental Health
U.S. Centers for Disease Control and Prevention

“The findings and conclusions in this presentation have not been formally disseminated by
the Centers for Disease Control and Prevention and should not be construed to represent
any agency determination or policy.”

U.S. Health Care Expenditures
as Percent of GDP Projections

Keehan et al:
Health Affairs
March/April 2008 27: 145-155

Injury -Vehicle Crashes

For every age group
from 3 through 33--
crashes were the No. 1
cause of death

Miles per capita– more than
doubled in one generation

Miles per Capita: 1960 to 1995 From 4,000 to 9,200
VMT per person

Disease in the 21st Century
• Mental Disorders: Depression,
Anxiety, Developmental, Substance
Abuse
• Macro-environment: Climate, Conflict
• Aging Populations
• Overweight: Chronic Diabetes II,
Heart Disease

Climate-
The European Heat Wave of 2003
Excess deaths
France 14,802
Germany 7,000
Spain 4,230
Italy 4,175
UK 2,045
Netherlands 1,400
Portugal 1,316
Belgium 150
TOTAL 35,118
Source: Earth Policy Institute

Recovery from surgery

• All cholecystectomies in a
Pennsylvania hospital, May-
October, 1972-1981
• Exclusions: age <20 or >69;
serious complications; history
of psychological problems
• Matched pairs: “tree view”
patients with “brick wall
view” patients

Recovery from surgery

Results: The “tree view” patients had
• shorter hospitalizations (8.70 days vs 7.96 days)
• less use of analgesic medications
• fewer negative nurse notes (e.g. “needs much
encouragement,” “upset and crying”)

Ulrich, Science, 1984

Trees and urban Life
Studies in Robert Taylor Homes,Chicago
• 28 identical high-rise buildings along a 3-mile
corridor
• Some have nearby vegetation, others do not
• Residents randomly assigned to apartments
• A “natural experiment”

University of Illinois
Human-Environment Research Lab
William Sullivan, Frances Kuo
http://www.herl.uiuc.edu/

Robert Taylor Homes interview study

• 145 residents
• Asked about social
dynamics and
aggressive behavior
• Compared answers
from people living
with and without
nearby nature

Strength of Community
Positive Interactions
no trees
very

trees

quite

somewhat

a little No No No
Trees Trees Trees

not at all
Know People Know Next Unity / Cohesion
on Floor Door Neighbor

no trees
very

trees

quite

somewhat

a little

No No No
Trees Trees Trees
not at all
Many Visitors Socialize Know People
Daily within Bldg. in Bldg.

no trees

very
trees

quite

somewhat

a little
No No
Trees Trees

not at all
Acknowledge Help
Each Other Each Other

Aggressive behavior against partner
Negative Interactions
.6
no trees
trees
.5

.4

Proportion .3
Yes

.2

.1
No No No No
Trees Trees Trees Trees
0

spiteful threatened threw or threw at
to hit smashed partner

.6
no trees

.5 trees

.4

Proportion .3
Yes

.2

.1
No No No No
Trees Trees Trees Trees
0

Hit with Hit with Beat them Used gun
something fist up or knife

1.6
no trees
1.4

1.2 trees
Mean Values

1

0.8

0.6

0.4

0.2 No No No
Trees Trees Trees
0
Psychological Mild Violence Severe Violence
Aggression

Aggressive and Violent Behavior

Inactivity, Overweight & Health
Evidence links inactivity and overweight with…
Inactivity Overweight
Increased mortality
Cardiovascular disease
Cancers
Depression
Gall bladder disease
Osteoporosis
Dyslipidemias
Hypertension

Relationship Between BMI and
Risk of Type 2 Diabetes
100 93.2
Age-Adjusted Relative Risk

Men

75 Women

54.0
50 40.3 42.1

27.6
21.3
25 8.1 15.8
2.9 4.3 5.0 11.6
2.2 6.7
1.0 1.5 4.4
1.0 1.0
0
<22 <23 23 24 25 27 29 31 33 35+
- - - - - - -
23.9 24.9 26.9 28.9 30.9 32.9 34.9
Body Mass index (kg/m2)
Chan J et al. Diabetes Care 1994;17:961.
Colditz G et al. Ann Intern Med 1995;122:481.

Percentage of US Adults with
Diagnosed Diabetes - 1994
1 state exceeds 6%

2 states exceed 9%

10 states exceed 9%

Sam’s Check Up

10 year old boy

“Problem” List
• Physical exam unremarkable
• Ht 54” (50%)
• Wt 115# (95%)
• BP 140/90
• Blood glucose elevated, urine normal
• Cholesterol 220
• Signs of Depression

Treatment Plan

• Weight loss program
• Referral to “overweight” clinic
• TV out of the bedroom; no soft drinks in
the house
• Exercise program; Encourage sports

"Outstanding in Its Field"

Hubbard Lake Elementary School, Hubbard Lake, Michigan.

Joe’s house

Destinations are not
connected.
Park

Sam’s house

PP slide courtesy of Doug Allen

Two Months Later…
• Lost One pound
• Can’t change the food at school
• Day is already too full
• No Time for exercise; “not good at
sports”
• No place to Walk

2 months later our patient could
be taking:
– Antihypertensive
medication
– Oral Hypoglycemic
agent
– Cholesterol lowering
agent
– Antidepressant
• Monthly medication
costs: $385

• The “environment” is rigged against
the patient…
• And the doctor.

Obesity Trends* Among U.S. Adults, BRFSS
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

5 states over 10%

1985
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: Mokdad AH, et al. J Am Med Assoc 2001;286:10.


1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16, 2001;286:10.


5 states over 15%

1991
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


1992
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


1993
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


1994
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


1995
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


1996
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


3 states over 20%

1997
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


1998
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


1999
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


2000
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


Alabama over 25%

2001
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


2002
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


2003
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


2004
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


2005
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


2006
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


Only
1 state under 20%

2007
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

BMI US Females 1988-1994

NHANES -- Measured
NHANES – In person interview-- self-reported

BRFSS – Telephone Interview

download from CDC at:
www.cdc.gov / nccdphp / dnpa / obesity / trend / maps
The data shown in these maps were collected through the CDC’s Behavioral Risk Factor Surveillance System (BRFSS).

Creating or improving access to places for
physical activity can result in a 25% increase
in the percent of persons who exercise.

•www.thecommunityguide.org
•AmJ Prev Med 2002

Walking
good for…
Obesity!
Heart disease!
Cancer!
Depression!
Diabetes!
Gall bladder!
Social life!

Higher density and connectivity Lower obesity
Atlanta study 2004

res sion
↓ Dep

↓ CO2 ↓ Air
emissions pollution

↑ Physical activity
↓ Osteoporosis

↓ Injuries

And by the way…
↓ Infrastructure costs ↑ Social capital

The sidewalk level:

The National
“Never Walk”
Campaign

12 Strategies

Strategy #1:

Don’t Build Sidewalks

Strategy #2:

Build Repellant Sidewalks

Strategy #3:

Allow Sidewalks to Disintegrate

Strategy #4:

Build Treacherous Sidewalks

Strategy #5:

Obstruct Sidewalks

Strategy #6:

Use creative design.

Strategy #7:

Crosswalks should be
dysfunctional, if not silly.

Strategy #8:

Combine Multiple Strategies

Strategy # 9:

Never place an interesting or
useful destination within walking
distance of where anybody lives

Strategy # 11:

Turn places to park
into architectural icons.

Strategy # 12:

Make everything car-accessible.
Everything!

Tobacco

Photo courtesy of Lyle McCoon, Jr., Nicholasville/
Jessamine County (KY) Parks & Recreation

Gambling

Photo courtesy of Lyle McCoon, Jr.,
Nicholasville/ Jessamine County
(KY) Parks & Recreation

A nice touch…
Braille buttons for
blind drivers

Banking

Drive-thru
sewer
payments:
Mt. Juliet,
Tennessee

Tunnel of Vows Drive-Thru Wedding Chapel
Las Vegas, NV

Gardner Memorial Chapel Junior Funeral Home
Davidson, TN Pensacola, FL

Drive-Thru Funerals

The next frontier of drive-thru:
Health care?

Resources
Healthy Places web Site:
www.cdc.gov/healthyplaces
BRFSS– data and trends regarding public health:
http://www.cdc.gov/nccdphp/tracking.htm

2008 guidelines Physical Activity Guidelines:
http://www.cdc.gov/physicalactivity/everyone/g
uidelines/adults.html

Dee Merriam- 770-488-3981- dmerriam@cdc.gov

Dee Merriam
770-488-3981
dmerriam@cdc.gov
www.cdc.gov/healthyplaces

Em

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