America faces a national health crisis of epidemic proportions. Physical inactivity combined with overeating has, in just a few decades, made us a nation of overweight and out-of-shape people.

The number of overweight and obese adults increased steadily from 47 percent in 1976, to 56 percent in 1994, and 61 percent in 1999. In 1999, 13 percent of children aged 6 to 11 years and 14 percent of adolescents aged 12 to 19 years in the United States were overweight, nearly tripling the numbers from two decades ago. These trends are equally alarming in California. Between 1990 and 2001, the number of people considered obese increased from 9.8 to 21.9 percent.

The reason we're getting fat

Clearly, the obesity epidemic has its origins in both excessive eating and inadequate exercise. A British Medical Journal article asked "Obesity — Gluttony or Sloth?" And concluded that sloth was the more significant contributor.

The popular press and the scientific literature are full of reports linking the value of physical activity with the prevention of a variety of diseases including obesity, heart disease and diabetes.

Yet, despite universal agreement among health professionals that physical activity provides enormous benefit in both the prevention and treatment of obesity and obesity-related diseases, and despite strong advisories for physical activity from the most authoritative health sources in the United States, including the National Institute of Health, Centers for Disease Control, and the U.S. Surgeon General, only a small minority of the American population pursues even the most modest levels of physical activity.

Lack of walking costs California counties

A study of individuals age 15 and older without physical limitations found that the average, annual direct medical costs were

$1,019 for those who were regularly physically active and $1,349 for those who reported being inactive. Being overweight increases yearly per-person health care by $125 and being obese costs $395 annually

When do issues of obesity and overweight become a societal issue in need of government intervention? According to a recent report in the Journal of Obesity Research, the public sector — counties, states and the federal government — covers the cost of about 50 percent of obesity-attributable expenses.

The obesity-related costs in California — the highest of any state in the nation — are estimated to total $7.7 billion per year. Medicaid and Medicare programs cover only $3.4 billion of these costs — a little less than half.

Sadly, the costs don't stop at the government level. Local business is paying a premium for an inactive workforce. A 2003 study conducted in Michigan found physical inactivity resulted in the loss of 162 productive hours per worker for a statewide cost to employers of $8.6 billion in 2002. Ultimately, Michigan residents absorb these costs in higher taxes and increased cost of goods. On average, physical inactivity cost each Michigan adult resident $1,175 in 2002.

Ways to address the crisis

According to California's new public health officer, Dr. Richard Jackson, "Cities should be designed to entice us to walk and connect with other people. We need to have the choice of spending less time in our cars. Just walking 20 more minutes a week will prevent a pound of weight gain a year — that's the amount the average American is gaining today — a pound a year."

A considerable body of research now establishes that "sprawl" — as measured by low residential density, low employment density, low "connectivity" and other indicators — is associated with less walking and bicycling and with more automobile travel than with denser communities. This research also confirms that we can help people incorporate physical activity into their daily lives by modifying business‑as‑usual, auto‑oriented land use planning.

The role of public health officials

In 1999, the National Association of County and City Health Officials (NACCHO) adopted a resolution stating that the organization, "Encourages the development of a permanent process for integrating the work of local public health into all phases of community‑based land use planning processes." Reportedly, four percent of the nation's local public health offices are now starting to talk to their planning departments.

Some health departments in Colorado, Washington and Michigan are conducting health impact assessments. Outside of Denver, the environmental health policy coordinator for a regional health department is evaluating development plans for three suburban counties. Her checklist includes an assessment of opportunities for walking, bicycling and transit.

King County, Washington is completing a study looking at transportation, land use, air quality and health connections. The results will be used to create planning policies, including development patterns that support physical activity in everyday life.

Here in California, the director of public health for Riverside County, Susan Harrington, is working with a major developer to plan two new communities as models for healthy living.

Making progress

According to the American Planning Association, progress is being made in making new development more activity-friendly and modifying existing development to make it more walkable. Eighty-one percent of respondents to their recent survey say they have enacted a mixed-use ordinance, 72 percent require or recommend that bicycle and pedestrian trails be incorporated into new developments, 68 percent require open space to be preserved in new developments and 62 percent have revised ordinances or plans to increase development densities to make new neighborhoods more walkable and transit-friendly

In California, some counties — among them Yolo, Ventura and Santa Clara — focus on directing new development into cities. This practice should lead to more compact cities and towns that can be more easily traversed by foot, bicycle or transit. At the same time, these policies preserve attractive open space for recreational hikers and cyclists.

One Northern California county is facing huge development pressures and a backlog of already-entitled projects. They are looking at how to make new development more walkable. In Yuba County, for instance, the Board of Supervisors and Community Development Department are working with developers to create quality, innovative communities. This work includes the mixing of housing types and densities; integration of commercial and residential uses in close proximity to one another; creating more pedestrian-friendly walkable communities; quality utilization of landscaping; professional architecture of structures and working with the natural features of a property to turn site constraints into amenities.

At a recent forum attracting 100 people in this small, rural county, residents and developers alike voiced strong support for these features.

Sources of assistance

The Active Living Leadership Initiative, supported by the Robert Wood Johnson Foundation, offers a Leadership Action Strategies Guide to support healthy community design. The guide offers more than 100 policies and programs that government leaders can adopt.

To assist each jurisdiction in determining their own costs related to physical inactivity, Active Living Leadership has developed a cost calculator that estimates the medical cost, workers' compensation and sick leave costs for communities and business, small and large. This information should provide local and state leaders, policymakers and business professionals a resource when considering budget allocations, policy options and the health/fiscal benefits related to increasing opportunities for physical activity.

The foundation is currently supporting activities undertaken by the Local Government Commission, International City/County Management Association (ICMA), National Association of Counties (NACo), and others, to educate local government leaders about the importance of creating places where people can incorporate walking into their everyday lives. The Local Government Commission is funded to provide direct technical assistance to selected California jurisdictions.

California's Department of Health Services has established the Healthy Transportation Network, in partnership with the Local Government Commission, the Rails to Trails Conservancy, and the California Bicycle Coalition to provide local elected officials assistance in creating active living environments for their residents.

Issues of overweight and obesity are not solely the responsibility of individuals. People need supportive environments that enable them to make healthy lifestyle choices. Local, regional and state government authorities are responsible for those decisions that shape the design of communities and as such, need to investigate innovative strategies and alternative resource allocation methods that improve health and quality of life for their residents.

And not to be sneezed at — a five percent increase in physical activity levels in the California population could produce cost benefits of $1.5 billion per year.

Resources

• Active Living Leadership*
  (www.activelivingleadership.org)
• Active Living Research*
  (www.activelivingresearch.org)
• Healthy Transportation Network
  (www.healthytransportation.net)
• International City/County Management Association
  (www.icma.org)

*Programs of the Robert Wood Johnson Foundation.

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