Advancing Obesity Solutions Through Investments in the Built Environment

Proceedings of a Workshop--In Brief September 2017

The built environment—the physical world made up of the homes, buildings, streets, and infrastructure within which we all live, work, and play—underwent changes during the 20th and 21st centuries. These changes contributed to a sharp decline in physical activity and affected access to healthy foods, which added to the weight gain observed among Americans in recent decades.1,2,3 As such, policies and practices that affect the built environment could affect obesity rates in the United States and improve the health of Americans.

On September 12, 2017, the Roundtable on Obesity Solutions, which is part of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine, held a workshop titled Advancing Obesity Solutions Through Investments in the Built Environment. The workshop examined how investments in the built environment contribute to the prevention and treatment of obesity and the overall health of communities, and it explored how to advance their effect. Specifically, presenters discussed successful multisector strategies that encourage physical activity and improve diet, equity, environmental justice, and overall community health and well-being, as well as discussed approaches for scaling up and institutionalizing these strategies to advance obesity solutions.

This Proceedings of a Workshop–in Brief highlights key points made by workshop participants during the presentations and discussions and is not intended to provide a comprehensive summary of information shared during the workshop.4 The information summarized here reflects the knowledge and opinions of individual workshop participants and should not be seen as a consensus of the workshop participants, the Roundtable on Obesity Solutions, or the National Academies of Sciences, Engineering, and Medicine.

The Changing Built Environment

In his introduction to the workshop, James Sallis, distinguished professor of family medicine and public health at the University of California, San Diego, provided a broad overview of how the built environment can affect obesity. Throughout 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, people walked on the streets, despite having to dodge obstacles like horses, streetcars, and other pedestrians. Then, motor vehicles took over the streets, and “everything changed,” said Sallis. “This may be one of the biggest experiments in human history, and we are now starting to evaluate the outcomes on health.”

The change from walking to using cars as the primary mode of transportation took many forms, Sallis observed. Zoning laws that separated residential, commercial, and industrial uses affected walking patterns, and as a result, homes were separated from jobs and commerce. 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.” Sallis 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 observed that increasing awareness of the links among the built environment, physical activity, and obesity has led to new insights, but he noted, “We are still building places that we have evidence are going to cause ill health,” and “Many people, if not the majority of people, in the United States are living in places that create ongoing serious barriers to healthy eating and active living.” He closed by stating, “There is much more to be done.”

James Sallis, UC San Diego, described how the built environment can affect obesity in the introduction.

Built Environments, Obesity, and Health

Urban planning and design decisions influence health and well-being through a variety of direct and indirect pathways (see Figure 1), and each of these pathways points to a series of interventions that can affect health outcomes, said Rodrigo Reis, professor of public health at Washington University in St. Louis, Missouri. Reis described a comprehensive framework that provides a series of interventions that can be implemented at different levels (local, regional, etc.) and solutions that can be applied in different parts of the world. To be successful, Reis explained, these concepts require proper governance and accountability (someone needs to be able to invest time, money, and political will), community participation and input, and attention to equity and inclusion. These interventions go well beyond the health sector, he explained, and are meant to be used by all sectors and disciplines.

Coordination among different urban policies, including transport, employment and economic development, social and health services, education, land use and urban design, housing, public open space and recreation, and public safety, is key, said Reis. “We need coordinated action in designing and planning cities so we can actually change transportation modes and daily [living] outcomes,” such as access to employment and education, food and health services, and social and recreational resources, he explained. Reis noted that the framework not only aims to improve physical activity and access to healthy food choices but also to reduce exposure to risks, such as traffic, air pollution, and prolonged sitting. Reis also described a set of indicators, including legislation and policies, government investments in transportation, urban and transportation planning and design, and transportation outcomes, to monitor a city’s progress in improving the built environment for health. Cities that monitor these indicators “are better able to … invest smartly,” according to Reis.

Reis suggested one way to facilitate this integration: emphasize not just positive health outcomes, but also the other benefits of changes to the built environment when engaging with nonhealth sectors. “Let’s think about how we can message the work around urban planning, city design, and health, [taking] a more comprehensive and effective approach,” said Reis.

Transportation and land use mediate the built environment’s effect on health through factors such as street connectivity, traffic, bicycling infrastructure, and access to mass transit, explained Daniel Rodriguez, chancellor’s professor in the Department of City and Regional Planning at the University of California, Berkeley. For example, he cited recent research that found that higher levels of street connectivity were associated with higher rates of walking. Rodriguez explained that connectivity is more than just adding sidewalks, because sidewalks alone are not enough to get people in low-density areas walking. He noted, “We want sidewalks that give us connectivity and lead to places and connect us with places.” He also observed that when walkability is defined as a combination of density, land use mix, connectivity, safety, and overall location, the walkability index is negatively related to the odds of being overweight or obese. “The whole package is more important than the ingredients,” he argued.

More than half of the U.S. population currently lives in suburban environments, observed Rodriguez, amounting to more than 170 million people. At the same time, almost every city in the United States has the potential for improving its built environment, he continued, noting that this demonstrates “the magnitude of the task ahead of us.” Planners, he argued, are at the heart of the issue, both as a contributing cause and as a remedy. The immediate challenge, said Rodriguez, is to combine changes in transportation, land use, and community development in such a way as to make a difference.

Karen Glanz, George A. Weiss University professor and director of the Prevention Research Center at the University of Pennsylvania’s Perelman School of Medicine and School of Nursing, turned her attention to the aspects of the built environment that determine the food environment. The food environment, Glanz explained, is made up of all of the places where people can find food, encompassing everything from the foods for sale in grocery and corner stores, restaurants and fast-food outlets, worksites, and schools. Then, she noted, there are the policies (e.g., school food policies, catering policies) and economic factors (e.g., taxes, food assistance policies, price supports) that dictate what foods are available. Glanz described how food environments are unique from physical activity environments and how food is complicated—it is a retail product, it is highly regulated, and food products are a big business—and she reiterated that environments are just one of many factors that influence what people eat.

Glanz then noted that there are associations between the food environment and a person’s body mass index (BMI), and between the food environment and diet quality, explaining that early research fi ndings suggested that supermarkets provide access to healthier foods and that fast-food restaurants contribute to obesity. Neighborhood food environments have been shown to vary greatly in ways that could contribute to differences in obesity prevalence, she explained. For example, Glanz described disparities in food environments, noting that more fast-food restaurants can be found in minority neighborhoods, some healthy foods are less available in disadvantaged and minority communities, and there are fewer supermarkets available (and they are less accessible) in low-income and minority communities. She cautioned that more intervention is needed than just ensuring access to supermarkets.

Interventions to change the food environments in schools, restaurants, and stores have shown mixed results, Glanz explained, but multicomponent community-wide prevention interventions that include community engagement, skill building, education, and environmental changes have shown promise, particularly for children. However, she explained that when environmental strategies are not effective, we have to step back and ask why: Was it the research (design, measures, execution)? Was the strategy not intense enough or not implemented well? Or was it because the wrong assumptions were being made? She cautioned that getting stuck on associations like “the supermarket is good” and “fast-food restaurants are bad,” might lead to people missing important nuances. The reasons why one intervention works over another are not always clear, she continued. “There are a lot of unanswered questions.” She observed, “How much environmental change is needed? How long will it take to improve behavior and health? Who [what population] changes after the interventions are implemented and do these changes reduce health inequity?”

In closing, she added that food environment changes cannot be discussed without thinking about other causes and side effects, such as food justice, social justice, and unintended consequences, stating, “I think we can all agree that everyone should have a right to healthy, affordable food.”

Examples from Communities and Cities

In the second session of the workshop, three presenters described the progress their cities, regions, and states have made in improving the built environment to advance obesity solutions.

In 2012 the Charlotte, North Carolina, region started a planning process called “Connect Our Future” to establish a shared vision for the region’s growth. The planning process involved more than 8,400 people in a “values-based discussion,” said Michelle Nance, planning director for the Centralina Council of Governments, which serves the greater Charlotte region. Local leaders led and had ownership of the planning process, which included the public, private, and not-for-profit sectors, explained Nance. The resulting plan had 10 growth priorities, which were based on a preferred growth map developed from scenarios of how the region wanted to grow and included different centers connected by regional transit. The growth plan also included more than 75 tools that local governments could use according to their own pace and appetite for change.

With support from the American Planning Association (APA) and the American Public Health Association (APHA), three tools from the long-range planning process—walkability audits, park access audits, and shared and open use policies—were chosen for implementation and applied to West Charlotte, one of the communities that has particular public health challenges, including lower household incomes, lower high school graduation rates, higher unemployment rates, higher violent crime rates, and a greater prevalence of heart disease, stroke, and diabetes than elsewhere in the county. Nance observed that starting at the local level was key to successful implementation: “Don’t start at the top … go to the local community where you have a principal that is really supportive.” Additionally, the department set out to understand the barriers and opportunities for physical activity in these neighborhoods, and developed walkability and park access audits that could be used with local residents. Nance explained that the audits offered a way to understand the barriers residents face and connect neighborhood offi cials with tools and information to make changes in their communities.

An important outcome of the walkability audits was that walking meetings build trust, said Nance, adding that local residents “were not only part of talking about the barriers, but they were talking through what some of the solutions may be.” The people closest to the problems understand them best, she observed, adding that inclusive planning can strengthen communities and increase feelings of trust and connection, which is especially important in underserved communities. Nance closed by stating that residents and local leaders can be empowered to be their own advocates for change.

Leslie Meehan, who oversees the Office of Primary Prevention in the Commissioner’s Office of the Tennessee Department of Health, described a metropolitan planning organization (MPO), which is a federally designated transportation planning authority found in all urban regions of the United States with 50,000 or more people. MPOs work with local governments to determine regional transportation priorities and to allocate resources to those priorities. “In short,” she explained, “they have the ability to set the policy, and they have the purse, they have the funding, so they are very important organizations to know.”

Meehan explained efforts by the Nashville Area MPO, which conducted a survey of 1,100 households to ask how local residents would spend transportation funds if they were in charge of the money. “What we resoundingly heard [from respondents in rural and suburban areas of the state] was that people wanted more mass transit, they wanted more walking and bicycling facilities, and they wanted to preserve existing roadways over building new roadways,” she said. Overall, the public expressed that it values choice, the ability to be physically active in its daily transportation routine, and time. Public policies shaped by this poll led to mobility solutions and opportunities for physical activity through new sidewalks, bikeways, and greenways and a new emphasis on Complete Streets, which are streets that have context-appropriate transportation facilities such as sidewalks, bikeways, and transit, she explained. She noted that the department concentrated these investments in health priority areas—areas with higher than average low-income, minority, and senior populations.

In addition, Meehan said that the Tennessee Department of Health hired seven health development coordinators, one for each of the seven regions of the state, to improve access to food and opportunities for physical activity, adding that new grants are enabling counties to plan, build, and evaluate the built environment infrastructure. Tennessee is one of just a few states that has a state-level “health in all policies” approach, Meehan continued. She noted that 12 state agencies are using existing resources to work together on issues of shared importance. In this way, state government can influence employment, livability, quality of life, and health all at the same time, said Meehan.

Cathy Costakis, who works for Montana State University-Bozeman and is a senior consultant to the Montana Department of Public Health and Human Services’ Nutrition and Physical Activity program, described the state’s efforts to build rural capacity and multisector partnerships and discussed why the state is focused on policy and planning. She explained that the work began in 2005 with its first capacity-building grant, starting with building relationships and understanding the policy implications and work within and across sectors. They first began to work on the built environment with local health departments, giving them each $15,000 to engage with city planners and city engineers and to talk about how to make changes.

To better understand its policy landscape, she said that in 2010 the state conducted a survey of communities with 1,000 people or more regarding its local policies related to active transportation. The survey found, for example, that only 38 percent of responding communities (83 percent of which were among the largest communities surveyed) reported a “gold standard” sidewalk policy for new development (meaning, a 5-foot-wide sidewalk was separated from the street by a boulevard planting strip) and only 5 percent of the communities surveyed had policies on bicycles. Costakis noted that this lack of policy is refl ected in the built environment, partly because the people affected by these policies (those people trying to walk, bike, and move around the community) are not included in the design of the community. Costakis illustrated this point, noting,

In many rural communities the only place to walk is on the rural road, and in many cases there is no shoulder. You are walking right in the road. And in Montana, a lot of those roads have 70-miles-per-hour speed limits. Do you really want your kids walking there?

She noted that school siting and sidewalk availability and connectivity are important to consider, especially in rural and low-income areas. Costakis focused on two case studies in the state. She described how the public health department in Lewis and Clark County, in which Helena is located, has been working with partners to get people biking and walking to work and schools since 2008. The department sought to convince the local government of the benefits of the built environment’s effect on public health, which led to the implementation of several policies and programs, including Complete Streets, Costakis explained.

In 2015 the department secured a Plan4Health grant from APA and APHA to develop the Greater Helena Area Active Living Wayfinding System, which identified trails, parks, community gardens, and other assets within the community. In this case, the system also included information on healthy foods, the library, and other destinations. The department also emphasized engaging all members of the community, including individuals with disabilities, to ensure there was a full understanding of where people want to go and what destinations are important to them. They also ensured that people of all ability levels were trained to be walk audit facilitators. Costakis also described efforts by an active transportation coalition to make an entire county a connected place for walking and biking, and another initiative that involved considering the number of people living within a 5-minute walk of a planned new food resource center prior to deciding where to build it. This effort resulted in ensuring that 124 people could walk or bike to the new location, compared to the 14 people who had the same access to the old site.

Costakis drew several lessons from this work in Montana, noting that the work encompasses multiple sectors and levels, from the state to the local level and from cities to small rural communities, and that capacity building is key. All change is local, and the community is the expert, she noted. Finally, she said, lighter, quicker, and cheaper pilot projects make it possible to try more things, and it is important to share successes and challenges.

Panelists discuss and field questions from the audience from session 2.

Achieving Equitable Healthy Environments

Equity is a major issue to address within the built environment and intentional policies and programs are useful to ensure more equitable outcomes, said Shiriki Kumanyika, professor emerita of epidemiology at the University of Pennsylvania’s Perelman School of Medicine and research professor in the Department of Community Health and Prevention at Drexel University’s Dornsife School of Public Health. She emphasized that a one-size-fits-all approach may not work for all population groups, particularly those that have been marginalized by policy or history. She also pointed out that approaches tailored to the community may be more effective in overcoming disparities. “We can achieve equitable communities if we are intentional, we know what the principles are, and we adhere to those principles,” said Kumanyika. The third session of the workshop looked at examples of such actions.

KaBOOM!, a national nonprofit organization that focuses on transforming the built environment to make it as easy as possible for all children—including those growing up in poverty—to play, has been motivated by considerations of equity throughout its history, stated James Siegal, chief executive officer of the organization. Siegal described how the organization seeks to build not only great parks and playgrounds, but also to integrate play into spaces where families and children are already spending time, including bus stops, grocery stores, health clinics, public housing facilities, and public elementary schools, a concept they call “Play Everywhere.” “It is shocking that in most major cities across the country, most elementary schools in underresourced communities do not have adequate play opportunities,” he said, noting, “You take it for granted in most communities, but it is not the case where most kids live.” Siegal emphasized the importance of community ownership in the entire process, stating,

Our process starts with the kids … and culminates with … a modern day urban barn raising for kids. It is a cathartic moment that makes people care about the changes that are happening in their community and gets them to think bigger about what is possible.

Siegal emphasized the special process involved with bringing a playground to communities:

It gets to creating safe spaces, and it gets to engaged communities that are going to care for kids. Our process starts with the kids. They design their dream playground, and then we help bring it to life. The process culminates with 200 volunteers coming together in a common purpose from various walks of life to build a playground in 6 hours.

In Alameda County, California, the goal of the public health department is that everyone in the county, no matter where they live, how much money they make, or the color of their skin, should lead a healthy, fulfilling, and productive life, said the department’s deputy director, Kimi Watkins-Tartt. To achieve this vision, she explained, the department focuses on policy and systems change, institutional change, and collaboration and partnership with members of the community. Community engagement, she emphasized, is one of the primary strengths of the department’s efforts to improve the built environment for the health of residents. “The challenge is to make sure that the people who we so often read about in the data are at the center of the conversation,” she said. Watkins-Tartt described three projects that the department has undertaken with contributions from the community: developing the health and wellness element of the Alameda County General Plan for the communities of Ashland and Cherry Hill, building healthy development guidelines for the city of Oakland’s planning department, and improving the food retail environment. In each of these efforts, she explained, the department worked directly with residents to make change. “They have to drive it. They have to shape it. And they have to own it.”

The Urban Land Institute (ULI), an 80-year-old nonprofit organization dedicated to promoting best practices in real estate development, launched its Building Healthy Places Initiative in 2013 to engage its membership—real estate developers, designers, investors, and others—and its partners in shaping places, projects, and policies in ways that improve the health of people and communities. Sara Hammerschmidt, senior director for content at the institute, said ULI’s private-sector members can promote health in three ways. First, in their own organizations ULI members can promote policies, such as worksite wellness programs, that boost the health of their employees. Second, in their investment and project decisions ULI members can promote healthy and thriving communities. And finally, in the influence ULI members have on communities they can support opportunities for people to be active or enhance their access to healthy food. Hammerschmidt explained that for a real estate developer, the term equity more often refers to the financial capital provided by investors to develop a project, rather than just and fair inclusion. To overcome this barrier, she continued, ULI is working to explain equity issues from a land use perspective to make the concept more relatable for their members. In addition, ULI encourages its members to form new partnerships with public health professionals and to learn the perspectives of other disciplines.

For example, Hammerschmidt described how ULI partnered with other built environment–focused membership organizations and APHA to release a joint call to action to promote healthy communities,5 encouraging their members to embrace collaboration across professions. Hammerschmidt described recent real estate development projects that bring together interdisciplinary groups to improve the health of residents as well as the surrounding community. For example, developers of the Aria community in Denver partnered with a local nonprofit to run an onsite greenhouse to provide healthy, affordable food to the surrounding community. “Innovative partnerships among real estate developers, nonprofit organizations, philanthropy, and community institutions,” Hammerschmidt noted, “can produce a development … that is really focused on improving health and equity.”

Finally, Shai Lauros, national health program director at LISC (Local Initiatives Support Corporation) National, described her organization’s efforts to bring capital investment from banks, foundations, investors, the public sector, and other sources together with technical resources from community development corporations, community action agencies, community-based organizations, and real estate development organizations to build community assets and local capacity. LISC approaches community development as a form of “transaction for transformation,” said Lauros, explaining that its approach is to bring local leaders together with residents to address the physical, social, and economic needs of a neighborhood and facilitate cross-sector partnerships while also assembling public and private capital to do the work.

She described several projects that resulted from the Healthy Futures Fund initiative, a collaboration among LISC, The Kresge Foundation, and Morgan Stanley to fi nance developments that connect health care and affordable housing for low-income communities. As one example, she described a project in Toledo, Ohio, that consolidated several specialized health clinics, a pharmacy, a community garden, and a credit union in one building, an approach she termed “healthintent housing.” By bringing together various on-the-ground partners—including residents—Lauros explained, LISC is able to take on new initiatives that have the potential to signifi cantly improve health. “We need to merge the conversations of equity in health and equity in development, workforce development, and social services,” she said.

Lauros described the partnership with local organizations as a sustainability mechanism. Communities, she explained, cannot be continuously subsidized, but by implementing best practices and revenue-generating opportunities, they can be sustained over a longer period of time. In addition to the many positive results from community development, Lauros noted that negative externalities are also associated with neighborhood change. Conversations are going on around the country about racial and geographic divides and gentrifi cation, said Lauros, and equitable development could to be part of these conversations. However, she cautioned that communities need to start early. “You will not be able to worry about [gentrification] later,” she warned.


Panelists discuss and field questions from the audience from session 3.

Moving Forward: Considerations and Potential Opportunities for Communities and Organizations

In the final session of the workshop, four panelists discussed potential opportunities for action gleaned from the earlier presentations and discussions.6 The panelists were Janet Fulton, epidemiologist and team lead in the Division of Nutrition, Physical Activity, and Obesity at the Centers for Disease Control and Prevention; Steve Lavrenz, technical programs specialist for the Institute for Transportation Engineers; Patricia Smith, senior policy advisor for the Reinvestment Fund; and Ken Wilson, a principal and design director of interiors in the Washington, DC, office of Perkins and Will. Monica Hobbs Vinluan, senior program officer at the Robert Wood Johnson Foundation, moderated the session.

Understanding and Meeting the Needs of Communities

Several members of the final panel raised the topic of the importance of understanding specific community needs and ensuring solutions address those needs from rural environments to large cities with diverse populations. Fulton began by reemphasizing a point made by several of the earlier presenters: understanding the needs and opportunities of communities at the local level may be useful for large-scale impact. “It is really important to meet communities where they are, to go in and ask questions about their needs,” said Fulton.

Taking action at the local level, Lavrenz observed, often requires personalizing issues that would otherwise remain abstract. For example, he explained that the Institute for Transportation Engineers has been emphasizing to its members that transportation might not be improved just for transportation’s sake. Rather, he suggested it could be tied to the idea of more livable communities and the specific ways in which people work and play.

Raising the importance of the indoor environment, Wilson observed that most people spend more than 90 percent of their time indoors. He noted that healthy design choices, such as incorporating natural light and making staircases appealing and accessible, can add value to a worksite. He pointed out that many new best practices, such as health and wellness rating systems, can cost relatively little, and organizational policies, such as reducing access to sugar-sweetened beverages, can also make businesses and workplaces more healthy and active.

Evaluating Impact

Implementing programs is essential, said Fulton, “but we need to show that they work.” For that reason, evaluation can be built into programs to establish a foundation of evidence, she said. She emphasized the importance of “not just collecting data for data’s sake, but data that matter and data that can help improve the lives of the people we are trying to affect.”

Smith suggested that for practitioners, demonstrating impact can help as they advocate for resources. “That is the first question you are usually asked: What difference does it make and how can you prove it?” Good evaluation sometimes requires questioning assumptions, Smith added. “If the evidence is starting to indicate that our original assumptions are not playing out, don’t be afraid to question them.”

Lavrenz discussed the importance of sharing data and performance measures with stakeholders, emphasizing the value of collecting data and tying them to health and transportation performance measures to persuade stakeholders in the transportation profession to become invested.

Communicating with Stakeholders

The role of the built environment in advancing obesity solutions can be conveyed to a variety of stakeholders, several of the panelists observed.

Fulton emphasized the importance of telling “really good stories.” Accounts of success and opportunity could be tailored to the targeted audience, she continued. “It can be decision makers. It can be parents. It can be kids themselves. But [tell] those stories with emotion—and also [try] to bring in the data that matter to them.” Smith described the challenge of messaging complexity to a society that is used to sound bites—“quick and simple is what you are under pressure to do.”

Framing messages correctly is critical in facilitating healthier communities, said Lavrenz. For example, when communities are hit by natural disasters, the process of rebuilding could be framed in terms of healthy, safe, and resilient communities.

The way those messages are delivered is also important, Vinluan observed. “Different messengers need to deliver different messages … [because] different things will resonate with different types of decision makers,” she stated.

Building Partnerships

The importance of partnerships was another point made by many of the presenters and by several members of the fi nal panel. Building partnerships requires good communication and listening as well as communicating, Fulton observed. “What does transportation need? What do decision makers need? What do parents need? If we enter those conversations in that way, we will be able to form those cross-sectoral collaborations in a better way.”

Many of the partners who need to be involved are not among what Smith called “the usual suspects,” adding that real estate developers are major infl uences in the built environment, yet they are not often involved in these conversations. “We have to open up the tent and really look beyond the usual suspects,” Smith said, continuing:

It might not be easy to invite people into our room, but we certainly can go into others, like conferences and meetings and opportunities to meet with other [potential partners]. I am talking about the developers, the bankers, and the business owners.

Smith also emphasized the importance of including young people as partners. “They are also not among the usual suspects. Getting and bringing in their voice is very important.” Wilson also emphasized that success requires engaging all stakeholders: “It is really multiple strategies that get you where you want to go.”

Closing Thoughts for Communities and Organizations

At the end of the session, the panelists provided closing thoughts for communities and organizations. Fulton suggested four potential action steps: (1) collect the data that matter; (2) form partnerships at all levels from the federal level to the local level; (3) think beyond the health benefi ts of improvements in the built environment; and (4) make the changes simple.

Smith focused on rural communities, which face unique challenges. To illustrate her point, she noted:

The issue of access is incredibly different in places like Montana or in places like Appalachia where geography can play a major role. It is not just about the built environment, but also other types of infrastructure like transportation and how does a truck of food or fresh produce get to places over long distances.

Lavrenz cited two potential action items. First, he described a transportation and health task force at the Institute for Transportation Engineers that has been developing short-, medium-, and long-term action items and goals. Second, he stated that health can be linked more explicitly to safety. “The two go hand in hand.”

Wilson said, “we need to practice what we preach.” His firm is participating in the Fitwel Champions program, which is a rating system that provides a road map to designing interior spaces that support wellness. “Health and wellness can be taught at the workplace,” he said. “If your organization has a policy that supports that, people learn about it, and then they take it home and tell their friends.”

Finally, Bill Purcell, former mayor of Nashville, Tennessee,7 asked all participants at the workshop to ask themselves what they and their organizations can to do change the built environment in such a way as to promote health. “What is your next step? How will you put into practice what you learned today?… There are defi nitely things that all of us can do … to create more healthy and equitable environments.”♦♦♦


Panelists discuss and field questions from the audience from session 4.
  1. Transportation Research Board and Institute of Medicine. 2005. Does the built environment influence physical activity?: Examining the evidence. TRB Special Report 282. Washington, DC: Transportation Research Board.
  2. Institute of Medicine. 2012. Accelerating progress in obesity prevention: Solving the weight of the nation. Washington, DC: The National Academies Press.
  3. Sallis, J., and K. Glanz. 2009. Physical activity and food environments: Solutions to the obesity epidemic. Milbank Quarterly 87(1):123–154.
  4. Presentations, videos, and other materials from the workshop can be found at (accessed October 27, 2017).
  5. See (accessed November 7, 2017).
  6. The information summarized here reflects the knowledge and opinions of individual panelists and should not be seen as a consensus of the workshop, the Roundtable on Obesity Solutions, or the National Academies of Sciences, Engineering, and Medicine.
  7. Currently with Farmer Purcell White & Lassiter, PLLC.

DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Steve Olson as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Kimberley Hodgson, Cultivating Healthy Places; James Sallis, University of California, San Diego; and Giselle Sebag, Urban Health Analytics. Lauren Shern, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.
SPONSORS: This workshop was partially supported by the Academy of Nutrition and Dietetics; Alliance for a Healthier Generation; American Academy of Pediatrics; American College of Sports Medicine; American Council on Exercise; American Heart Association; American Society for Nutrition; Bipartisan Policy Center; Blue Cross Blue Shield of North Carolina Foundation; The California Endowment; ChildObesity180/Tufts University; Edelman; General Mills Foundation; Greater Rochester Health Foundation; Health Partners; Healthy Weight Commitment Foundation; The JPB Foundation; Kaiser Permanente; The Kresge Foundation; Mars, Inc.; National Recreation and Park Association; Nemours Foundation; Nestlé Nutrition; Nestlé USA; Novo Nordisk; Obesity Action Coalition; The Obesity Society; Partnership for a Healthier America; Reebok, International; Reinvestment Fund; Robert Wood Johnson Foundation; Salud America!; Weight Watchers International, Inc.; and YMCA of the USA.
For additional information regarding the meeting, visit