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					Improving the 
Built Environment 
to Address 
Chronic Diseases


Karen K. Lee, MD, MHSc, FRCPC
Adjunct Professor, Schools of Public 
Health, University of Alberta and 
University of Toronto;
Also Director, Built Environment & 
Active Design, NYC Dept of Health 
and Mental Hygiene
   THE 19th CENTURY:                            THE 21st CENTURY:

             Infectious                            Chronic Diseases, 
                                                       many of which are 
              Diseases                                “Diseases of Energy”


                                               The emerging design solutions for 
   19th Century codes, planning and 
                                               health parallel sustainable design 
infrastructure as weapons in the battle 
                                                           solutions
       against contagious disease
                                               Effective designs will have to be an 
These strategies were built into the city 
                                             invisible, pervasive, and inevitable part 
    fabric, and they were effective
                                                               of life
100+ years ago, urban conditions were a breeding ground 
            for infectious disease epidemics

                         Over‐crowding
                       in Lower Manhattan 
                             1910 density: 
                        114,000 people/ sq. mi.
                                                      Major epidemics:

                            2011 density:          Air/droplet‐borne diseases:
                        67,000 people/ sq. mi.                 TB




                               +                     Water‐borne diseases:
                                                             Cholera

                                                     Vector‐borne diseases:
                      Inadequate systems                   Yellow‐fever
                      for garbage, water, and 
                         sewer, leading to 
                        pervasive filth and 
                      polluted water supplies   
The response was through built environment interventions

                     1842   New York’s water system established – an            
                            aqueduct brings fresh water from Westchester.


                     1857   NYC creates Central Park, hailed as “ventilation 
                            for the working man’s lungs”, continuing 
                            construction through the height of the Civil War


                     1881   Dept. of Street‐sweeping created, which eventually 
                            becomes the Department of Sanitation


                     1901   New York State Tenement House Act banned 
                            the construction of dark, airless tenement buildings


                     1904   First section of Subway opens, allowing population 
                            to expand into Northern Manhattan and the Bronx


                     1916   Zoning Ordinance requires stepped building 
                            setbacks to allow light and air into the streets
 The Results: Infectious disease rates

             BEFORE the wide use 
                of antibiotics!


57.1%         45.8%
                                     AFTER the wide use 
                                       of antibiotics!




               11.3%                2.3%
                                         9%
 1880            1940                   2011
                The epidemics of today are:

                 CHRONIC DISEASES
              (obesity, diabetes, heart disease 
                     & strokes, cancers)

                  Top 5 Causes of Death in U.S.:  

         1.Tobacco,  2. Obesity,  3. High Blood Pressure, 
            4. High Blood Sugar,  5. Physical Inactivity




Energy in:                                       Energy out: 
Food                                             Exercise
    Obesity and Diabetes have increased rapidly.
Our genetics have not changed in one generation, but 
             our built environment has!
Growing Evidence Base for Improving Health through Building, Street 
 Evidence-based Research shows that we can Increase Physical
 Activity through Building,
and Neighborhood Design Street and Neighborhood Design
 OOD SCALES
   Designing to      Point-of-Decision stair prompts
   increase stair        Signs placed at elevators & escalators encouraging stair use, w/ info on
   use                   benefits of stair use
                         Median 50% increase in stair use
                     Design and aesthetic interventions
                         Music & art in stairwells
                     Design stairs to be more convenient and visible
                     Skip-stop elevators
                          3300% increase in stair use

   Designing to
   increase active   Enhancing access to places for physical activity, such as creating
   recreation           walking trails or having onsite or nearby parks, playgrounds and
                        exercise facilities (homes & worksites)
                        increases leisure-time activity and weight loss

                     Walking, Bicycling and Transit-oriented development
   Designing to         Designs to improve street safety and aesthetics (less crime and traffic /
   increase active         more greening), having sidewalks and bike paths connected to
   transportation          destinations, mixed land use, high population density
                        Median increase in physical activity 35% to 161%
WE CAN ADDRESS THESE ISSUES AT THE BUILDING,
Growing Evidence Base for Improving Health through Building, Street 
STREET AND NEIGHBORHOOD SCALES
and Neighborhood Design
                  Increased access to healthy foods and beverages within food
  Increasing          Increased
                  environmentsaccess to healthy foods and beverages within food
  Access to           environments
  Healthy Food    Increased access to premises that provide healthy foods and
  and Beverages       Increased access to premises that provide healthy foods and
                  beverages – e.g. supermarkets, farmers markets, drinking water
                      beverages – e.g. supermarkets, farmers markets, drinking water
                  facilities
                      facilities


   Decreasing        Decreased exposure to unhealthy foods such as trans fats and
   Exposure to       sugary drinks
   Unhealthy
   Food and          Decreased exposure to unhealthy food premises
   Beverages



   Point-of-         Information at points of selection and purchase of food
   Decision
   Information
Translating Health Evidence into Non‐Health Policies Affecting Health
KEY LESSONS LEARNED:
• The Need for Partnerships – Core and Extensive
• Finding Synergies and Co‐Benefits
• Complementary Roles of Core Partners
    – Health:  Presenting the available research‐based evidence and the 
       epidemiology of disease; organized early meetings/conferences to do so
    – Design and Construction, Transportation and City Planning:  Ideas of what’s 
       feasible in the current local context; identifying opportunities and 
       mechanisms, including and especially synergistic efforts
    – Health:  Playing a supporting role for implementing ideas – presenting the 
       health evidence; assisting with strategy and planning, undertaking studies 
       to inform implementation planning and evaluation; providing resources for 
       coordination of intersectoral meetings, initiatives and follow‐up
    – Design and Construction, Transportation and City Planning:  Leadership and 
       participation in the efforts
    – Researchers:  evidence reviews and synthesis, evaluation research
• Garnering Review, Feedback and Inputs from an Extensive Group of Partners
• Using Evidence‐Based and Best‐Practice Strategies
• Using Annual Conferences as Strategic Milestones to Highlight Successes and 
   Craft Strategic Next Steps with Extensive Group of Partners
• Key Roles for Peer‐to‐Peer Partnerships and Mentoring among Cities
Fit City Conferences




  Fit-City:
  Promoting Physical Activity Through Design




          Fit-City 3:
          Promoting Physical Activity Through Design
The Active Design Guidelines
 Chapters
1) Environmental Design and Health: 
   Past and Present
2) Urban Design: Creating an Active 
   City
3) Building Design: Creating 
   Opportunities for Daily Physical 
   Activity
4) Synergies with Sustainable and 
   Universal Design




 www.nyc.gov/adg
Creation of the Guidelines
Active Design Guidelines Team
                                   New York City Staff*                    Department of City Planning          Editor
                                                                           Alexandros Washburn, AIA             Irene Chang, March, MPhil
                                   Department of Design and                Chief Urban Designer                 Cheng+Snyder
                                   Construction
                                   David Burney, FAIA                      Skye Duncan, MSAUD, BArch            Community, Academic and
                                   Commissioner                            Associate Urban Designer             Private Sector
 Michael Bloomberg                                                         Mayor’s Office of Management and     Ernest Hutton, Hutton Associates,
                                   Margo Woolley, AIA
 MAYOR                                                                     Budget                               INC.
                                   Assistant Commissioner,
                                                                           Joyce Lee, AIA, LEED AP              Ellen Martin, 1100 Architects
                                   Architecture and Engineering
 David Burney                                                              Chief Architect                      Linda Polack Marpillero Pollak,
                                   Division
 COMMISSIONER                                                                                                   Architects
 Department of Design and          Vitoria Milne, MID                      Academic Partners                    John Pucher, Bloustein School of
 Construction                      Director, Office of Creative Services                                        Planning and Public Policy,
                                                                           Craig Zimring PhD.                   Rutgers University
                                   Department of Health and Mental         Professor, Georgia Institute of      Jessica Spiegel, 1100 Architects
 Thomas Farley                                                             Technology
                                   Hygiene                                                                      William Stein, Dattner Architects
 COMMISSIONER                                                              College of Architecture              Shin-Pei Tsay, Transportation
 Department of Health and Mental   Karen Lee, MD, MHSc, FRCPC                                                   Alternatives
 Hygiene                           Director, Built Environment             Gayle Nicoll, M.Arch, PhD, OAA
                                                                           Associate Professor and Chair,       Thanks to all the design
 Janette Sadik-Khan                Sarah Wolf, MPH, RD                     University of Texas at San Antonio
                                   Built Environment Coordinator                                                practitioners and organizations
 COMMISSIONER                                                              Department of Architecture           who participated in the 2009
 Department of Transportation      Department of Transportation                                                 Design Charrette to help test the
                                                                           Julie Brand Zook, M.Arch
                                   Wendy Feuer, MA                         Researcher, Georgia Institute of     Guidelines prior to its publication.
 Amanda Burden                     Assistant Commissioner of Urban         Technology
 COMMISSIONER                      Design and Art, Division of Planning    College of Architecture
 Department of City Planning       and Sustainability                                                           *We also thank the many city
                                                                           Reid Ewing, PhD                      agencies that gave input including
                                   Hanna Gustafsson                        Professor, University of Utah,       the Depts of Parks and
                                   Former Urban Fellow, Division of        Department of                        Recreation, Buildings, Housing
                                   Planning and Sustainability             City and Metropolitan Planning       Preservation and Development,
                                                                                                                School Construction Authority,
                                                                           American Institute of Architects     Aging, and Mayor’s Offices of
                                                                           New York Chapter                     Long-Term Planning and
                                                                           Fredric Bell, FAIA                   Sustainability, and of People with
                                                                           Executive Director                   Disabilities.
                                                                           Sherida Paulsen, FAIA
                                                                           2009 President
IMPLEMENTATION: Inter‐Sectoral City Policy Initiatives on 
Built Environment

    Synergies:
    • Health
    • Safety
    • Environmental 
      Sustainability
    • Universal Accessibility
    • Economic Benefits




www.nyc.gov/adg
  Co-benefits of Active Design: Improve the Environment


                            Fuel / Electricity Use   Air Quality   Obesity/Diabetes/
                                                                     Heart Disease
Biking or walking rather              √                  √                 √
than automotive 
transport
Stairs rather than                    √                  √                 √
elevators and escalators


Active recreation rather              √                  √                 √
than television


Safe tap water rather                 √                  √                 √
than bottled and canned 
beverages
Fresh local produce                   √                  √                 √
rather than unhealthy 
processed foods
Co‐benefits:  Create more accessible places


 • Creating safer places to 
   walk, take transit, & for 
   wheelchair travel

 • Making elevators more 
   available for those who need 
   them
Co‐benefits: Reduce infrastructure costs

More compact, walkable development patterns save money 
on avoided infrastructure costs

                                 Water & Sewer               Water & Sewer                 Road Lane Miles               Road Land Miles 
                                 Laterals Required           Costs (billions)              Required                      Costs (billions)


  Sprawl Growth                             45,866,594               $189.8                              2,044,179               $927.0
  Scenario

  Compact Growth                            41,245,294               $177.2                              1,855,874               $817.3
  Scenario

  Savings                                    4,621,303               $12.6 (10.1%)                         188,305               $109.7 (6.6%)




  Sprawl Costs: Economic Impacts of Unchecked Development, Robert W. Burchell, Anthony Downs, Barbara McCann and Sahan Mukherji, Island Press, 2005
Co‐benefits: Save people money




         People in walkable, transit‐rich neighborhoods spend only 
     9 percent of their monthly income on transportation costs; those in 
             auto‐dependent neighborhoods spend 25 percent. 

     Source: Center for Transit‐Oriented Development
Co‐benefits: Create jobs

                                        Building bicycle 
                                        and pedestrian 
                                        infrastructure 
                                        creates more 
                                        jobs per dollar 
                                        invested, 
                                        compared to 
                                        road 
                                        infrastructure 
                                        only




                           Source: Political Economy 
                           Research Institute: June 2011
Co‐benefits: Create desirable places to live, work & play
                     Sprawl Community :                                            Smart Growth Community : 

                      Preferred by           43%                                        Preferred by       56%
                                                                               There is a mix of single‐family detached houses, 
          There are only single‐family houses on large lots                    townhouses, apartments, and condominiums on 
                                   Karen Lee, MD, MHSc, FRCPC,                                 various sized lots

                                   NYC Dept. of Health & 
                         There are no sidewalks
                                                                 Almost all of the streets have sidewalks

                                   Mental Hygiene Places such as shopping, restaurants, a library, 
           Places such as shopping, restaurants, a library, 
             and a school are within a few miles of your       and a school are within a few blocks of your 
                                   Skye Duncan, NYC Dept. of 
               home and you have to drive most places             home and you can either walk or drive

                                   City Planning
          There is enough parking when you drive to local     Parking is limited when you decide to drive to 
                                   Story  K. Bellows, Mayors’
                  stores, restaurants, and other places         local stores, restaurants, and other places

                                   Institute on City Design
          Public transportation, such as bus, subway, light  Public transportation, such as bus, subway, light 
                                                                      rail, or commuter rail, is nearby
                                    The Honorable Deke 
           rail, or commuter rail, is distant or unavailable


                                   Copenhaver, Mayor, City of 
                                   Augusta, GA 
Source: NAR National Poll, 2011 Q: In which community would you rather live?
City Policy + Implementation
   NYC STAIR PROMPT            CAMPAIGN
Stair Prompt Campaign
Development:  
• Partnership with DDC, GreeNYC, AIANY, 
  REBNY
Dissemination:
• Free to all building owners, managers, tenants 
   who call 311 to order
• ~30,000 signs disseminated to owners and 
  managers of >1,000 buildings
Evaluation:
• 10‐Story Affordable Housing Site in the South 
   Bronx
    – Relative increase in stair use after stair 
       prompt:  as high as 67%; >40% (p<0.001) at 
       9 months
• 3‐Story DOHMH Health Clinic in Northern 
  Manhattan
   – Relative increase in stair use “up”: >20% 
      (p<0.001)
City Policy + Implementation
Use of LEED Green Building Credits that Promote PA
  Development density
  and community                Public transportation   Bicycle storage and 
  connectivity                 access                  changing rooms
Creation of LEED Physical Activity Innovation Credit
(Siting near schools, Adult and children’s active recreation spaces, Gardening space, Stair
use promotion strategies )
                                                                                  st
  Developed through a public‐private partnership; used NYC Health Dept Clinic as 1 building

  Projects across U.S. using Credit – 6 approved (NYC); >10 more in progress (incl. NYC, California, Miami)

 Detailed information is available at: 
      www.1100architect.com under Sustainability (Riverside Health Center)
      www.brightpower.com under Green Buildings (Via Verde Affordable Housing)
City Policy + Implementation
NYC FRESH Program

                                FRESH Food Store Areas 
                                where zoning and 
                                financial incentives 
                                apply

                                Additional areas where 
                                FRESH financial 
                                incentives may be 
                                available




Zoning and tax incentives for providing fresh food options
in the city’s underserved areas with high health needs
City Policy + Implementation
NYC Green Codes




                   Increasing drinking water access through better tap 
                   water facilities – passed in Plumbing Code
City Policy + Implementation
NYC Green Codes




             How do we incentivize good stair design and remove 
             barriers to stair use through Zoning and Building 
             Codes?
City Policy + Implementation
Zoning for Bicycle Parking




                   Zoning for Bicycle Parking:
                   Increasing active transport by providing 
                   safe and secure parking for bike commuters
City Policy + Implementation
NYC World Class Streets




                               Remaking NYC’s public realm:
                               • Street Design Manual
                               • Plaza Program
                               • World Class Boulevards
                               • Complete Streets Projects and 
                                 Design Standards, incl. bike lanes
                               • Public Art Program
                               • New Streetscape Materials
                               • Coordinated Street Furniture 
                                 Program
                               • Weekend Pedestrian and 
                                 Cycling Streets
City Policy + Implementation
Creation of Additional Active Spaces:  Summer Streets
• DOT closes Park Avenue to traffic from 
  Brooklyn Bridge to Central Park and the 
  Upper East Side on Saturdays in August

• Evaluation:  
     – Average amount of physical activity 
       from distances walked, ran, biked on 
       route:  >40 minutes of vigorous 
       physical activity, or >70 minutes of 
       moderate physical activity
     – 24% of people were those who didn’t 
       meet PA Recs
     – 87% of participants got to event by 
       active modes
     – High Needs Neighborhoods and 
       Neighborhoods Outside Manhattan 
       underrepresented
City Policy + Implementation
Creation of Additional Active Spaces:  Playstreets




                                                  Green = 
                                                 Community 
                                                   Sites

                                                Red = School 
                                                   Sites
Playstreets
 On request of DOT, Playstreets Coordinator hired by Health


 Evaluation by Health:

 Ages of children attending Playstreets (from surveys): Ages 1‐13

 Visited Playstreets at least once before:  >80%

 Average length of time children stayed at the Playstreet (from surveys): 
    ~1.5hours

 Most likely activity if children had not come to the Playstreet:
         TV or other inside activity:                      52%
         Outdoor activity:                                 38%
         Indoor or outdoor activity equally likely:        10%
Nationally in the U.S.:  CDC’s Investments in Creating 
Healthier Environments to Address Obesity and Tobacco
• Communities 
  Putting Prevention 
  to Work Funding 
  (2010‐March 2012)

• Communities 
  Putting Prevention 
  to Work Built 
  Environment 
  Mentoring Program 
  (2011‐June 2012) 
                                      Tobacco work

                                      Obesity work


                                      Both

                                      Built Environment Mentoring
          Built Environment & Health Partnership
          Built Environment & Health Partnership
 Supported by CDC
   Communities
Putting Prevention
to Work Mentoring
       grant

    Partnership
  between NYC
DOHMH, AIANY, and
 14 communities

  All communities
 are recipients of
  CPPW grants



       Boston MA ~ Cherokee Nation OK ~ Chicago IL ~ Cook County IL ~
  Douglas County NE ~ Jefferson County AL ~ King County WA ~ Louisville KY ~
Miami-Dade County FL ~ Multnomah County OR ~ Nashville TN ~ Philadelphia PA ~
                       Pima County AZ ~ San Diego CA

                              www.nyc.gov/adg
 NOW WE MUST ADDRESS THE EPIDEMICS OF OBESITY AND
 CHRONIC DISEASES
Coordinated Peer Mentoring Partnership
Key Intergovernmental Partners in Local Communities 
(n=15, incl. NYC):

•   Public Health – 15 
•   Planning – 15
•   Transportation – 14
•   Education/School Construction – 12
•   Parks and Recreation – 12
•   Public Works – 8
•   Housing Development or Management – 6
•   Buildings – 3
 NOW WE MUST ADDRESS THE EPIDEMICS OF OBESITY AND
 CHRONIC DISEASES
Coordinated Peer Mentoring Partnership
Non‐Governmental Partners in Local Communities
(n=15, incl. NYC):

•   Community‐Based/Non‐Profit Groups – 13
•   Environmental Organizations – 9
•   American Planning Association local chapter – 7
•   American Institute of Architects local chapter – 5
•   American Society of Landscape Architects local chapter – 3
•   Local Architecture, Planning and Design Institutions – 3
•   Building Owners and Managers Association – 1
Impacts
To date, NYC has…

• Won 4 National Awards (Health Policy, Environmental Protection,
   Sustainable Buildings, Architecture)
• Distributed >15,000 copies of ADGs nationally & internationally
• Trained >3,000 built environment professionals in NYC and U.S.
• Developed LEED Green Building Rating System Innovation Credits 
   for Physical Activity, Healthy Food and Beverage Promotion, and 
   Urban Agriculture
• Passed City Policies
• Issued 11‐agency Obesity Task Force Recommendations
• Mentored 14 other U.S. cities and communities
   (others now adopting initiatives such as integrating use of ADGs,    
   “Burn Calories, Not Electricity” Stair Prompts, Playstreets, Fit City)
Impacts
To date, NYC has…

•Increased:
       ‐ Commuter cycling 262%
       ‐ Bus and subway ridership 10%
       ‐ Stair use ‐ >40% increase at 9 mos in 10‐story low‐income 
                    housing
       ‐ Places for children’s play ‐ ~40 new Playstreets permitted 

• Decreased:
     ‐ Traffic fatalities 30%
     ‐ Traffic volumes 25%
     ‐ Car registrations 5%

• Started Reversing Childhood Obesity (also in San Diego!)

				
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