A decade ago, most Americans would have characterized as “wacko” anyone thinking that the car-centric and sprawling form of the American metropolis was making people sick.
My Nashville Scene editor didn’t use that exact term when, in 1999, I pitched him a story on the subject. But he turned me down. I’d been reading articles by public health nerds about the tsunami of body fat engulfing our nation caused by our increasingly sedentary lifestyles. To blame suburban sprawl for an individual’s spread “sounds pretty fringe-y,” he said, as I recall. Two years later, the Scene gave cover billing to “Fat City: Is Nashville’s Car Culture Killing Us?”
What happened? Well, planners and the media started catching up with the nerds. The planners, conditioned to considering the functional health of the built environment, began publicly considering the physical health consequences of their land use and transportation plans. And the media began to converge on the not-so-healthy beat.
Articles, then books such as Urban Sprawl and Public Health (2004), first concentrated on diagnosis, examining the links between auto-dependent suburban form and physical inactivity. More recently, the focus has been on treatment. Books such as Making Healthy Places (2011) and the PBS documentary series Designing Healthy Communities, scheduled to air next year, offer curative actions for the built environment.
Now Nashville is getting its own prescription. This week the Nashville Civic Design Center (NCDC) announces Shaping Healthy Cities: Nashville. Scheduled for publication in 2013 by Vanderbilt University Press, the book will review various Nashville neighborhoods from the standpoint of access to mass transit and green space for recreation, the number and usability of sidewalks and bike lanes, and the opportunities to walk to shops and schools. An action plan will recommend corrective steps for our built environment and outline checklists that can be used to assess the health impacts of development decisions.
The seed money for Shaping Healthy Cities is a $150,000 grant from the Metro Health Department. This grant is in turn part of a $7.5 million federal award to the department to develop and implement strategies to impact health by changing community environments.
NCDC project coordinator Patricia Conway will work with design director Gary Gaston and a team of research assistants to gather data for the book. Then yours truly will write the call to action.
That action is called for is indisputable.
Americans are getting fatter — rapidly. In 2000 no state had an obesity rate of 30 percent or more, according to the Center for Disease Control (CDC), the Atlanta-based arm of the federal government charged with the nation’s public health agenda. Now 12 do, including Tennessee. That in 1990 the CDC reported Tennessee’s obesity rate as just over 10 percent indicates the pace of the spread in our waistlines.
Nashville’s profile is also plumping out. In 2001 the Metro Health Department found that 19 percent of our adult population was at risk of the myriad diseases — diabetes, heart disease, hypertension, stroke, respiratory problems, degenerative joint disease, certain cancers — associated with obesity. By 2009, according to department statistician Burns Rogers, the percentage of obese adults in Davidson County had risen to 33 percent. Even more alarming, the Metro Health Department reports that as of 2010, almost 15 percent of Nashville’s public high school students are obese.
The stats are compiled for the CDC via something called the Behavioral Risk Factor Surveillance System. States and some cities conduct surveys on the health indicators of their citizens, then report the data to the CDC. Obesity is determined by using weight and height to calculate a figure called “body mass index,” which in most people correlates with the amount of body fat.
Because weight and height are self-reported, and people tend to overestimate their height and underestimate their poundage, CDC researchers suspect that the actual degree of obesity is probably even greater than their figures. And the increase is across the board: All states, age groups, races, education levels and both sexes have registered escalating body fat.
The thickening of Americans isn’t just a health issue, but an economic one. A 2009 report in Health Affairs pegged the annual medical costs associated with obesity at $147 billion, double from a decade ago and more than 9 percent of all medical spending in this country.
As far back as 1999, the CDC was already describing the epidemic of obesity as a cultural phenomenon. In an article in the Journal of the American Medical Association, CDC researchers state that the increase in body fat “in all segments of the population and regions of the country implies that there have been sweeping changes in US society that are contributing to weight gain by fostering energy intake imbalance [eating more calories than we’re burning]. Such changes are unlikely to be due to diminished individual motivation to maintain weight or in genetic or other biological changes in the population.”
Urban planners digested the CDC data and looked out their office windows. What they saw was a built environment telling us to sit down and step on the gas pedal. Bingo.
For public health professionals trying to prevent disease, there are two general approaches: trying to change the behavior of individuals one by one or influencing the habits of the population at large through changes in environment. In the case of obesity, intervention with individuals — “the health club approach” — won’t turn the tide, said Metro Health Department director Bill Paul. “Never anywhere does a significant proportion of the population get involved in exercise that requires setting aside special time, changing clothes and going to a special place,” Paul says.
Mayor Karl Dean has emphasized the city’s parks and greenways as a free fitness tool. More than 4,000 Nashvillians walked more than 100,000 miles this summer as part of his Walk 100 Miles health initiative. And Hizzoner is asking us to train and then join him for a 5K walk or run in November.
Such campaigns “provide social support for exercise, which is great,” Paul said. “But by themselves, special programs aren’t a magic bullet [as] the effects often aren’t long-lasting.”
“A lot of everyday life is shaped by the built environment,” explained Paul. “Can kids walk to school, ride a bike safely? Can you walk to a store, to the bus? Research shows that bus riders get more exercise than drivers. We have to make it easier to move our muscles in daily life.”
Ever since the end of World War II, when planners put the automobile in the driver’s seat, we’ve designed a built environment “that does everything it can to inhibit physical activity,” said Metro Planning executive director Rick Bernhardt.
We segregated different land uses into nodes that require an automobile to connect them, developed subdivisions without sidewalks and transportation systems privileging the wide road and the long car trip.
According to stats from the Federal Highway Administration, Nashvillians drive an average of over 32 miles a day. Metro planner Jennifer Carlat said that the commute to work is a shrinking percentage of that total.
“It’s all the other trips,” she said. “Shops, schools and homes are so spread out,” and children and the too-old-to-drive require chauffeuring. The result: Many and increasingly lengthy trips are necessary to accomplish the tasks of daily life.
Metro’s planners are trying “to change the development direction by putting walkable, mixed-use communities back into the city,” Bernhardt said. Making land use denser and more mixed shortens the distance between destinations to walkable parameters. A connected network of streets, bike lanes and sidewalks, instead of a system of cul de sacs and arterials, further encourages us to connect the dots on our daily maps by nonauto means.
“And our arterial roads, which are very underdeveloped, offer huge opportunities for infill and making mass transit more sustainable,” Bernhardt says. He notes that OneCITY, a mixed-use complex with a health care focus planned for Charlotte Avenue at the new 28th/31st Avenue Connector, is a good example of exploiting the potential of pikes for denser, pedestrian and transit-friendly design.
Some corrective steps to incorporate movement into daily life can be taken with individual buildings. Placing staircases centrally and designing them as public amenities rather than vertical “mean streets,” for example, could be the tipping point for potential users.
Take the downtown public library, where the grand staircase is the first thing you see walking in the front door, while the elevator bank is tucked off a side corridor.
A case of missed opportunity is Metro’s Howard School office building, which recently underwent a major makeover. Here the elevator is centrally located just past security check-in. The staircases, on the other hand, are at the very ends of the building and require navigating a bewildering series of corridors and cubicles to reach them.
Bill Paul says even skyscrapers could be made more walkable. He acknowledges that no one will climb from floor 1 to 27. “But to get to floors 2 or 3 from the lobby by stairs is doable,” Paul says. “And if you have to go from floor 26 to 27, because your company has both floors, stairs could be a real option.”
According to the Metro Public Works Department, the first bike lane was installed in 2002 and the city now has 100-plus miles of such lanes and designated bike routes shared with cars. But the local culture can still be antagonistic to those who pedal.
NCDC intern Kathleen Russell described an encounter with a driver hostile to the very idea of bicycles on city streets. Russell was biking downtown on Church Street, and a woman in a large SUV passed her, then pulled over.
“She yelled, ‘Get off the road and onto the sidewalk — that’s what they’re for,’ ” Russell says. “I tried to explain that this was a designated bike route, but she said I had no business taking up the road.” For some the learning curve is steep.
Flattening the learning curve is the point of Shaping Healthy Cities: Nashville. And it will take more than advocating for better staircases and more bike lanes. Labor-saving devices — putting the laundry in the dryer rather than hanging it out on a sunny day — compulsive TV watching, computer addiction, a lack of access to healthy food in some neighborhoods and a shrinking pool of people who know how to cook it, all have made obesity a way of life for more and more of us.
One thing Shaping Health Cities won’t be, however, is a blueprint for the expenditure of more public monies.
“What we’re looking for isn’t more spending,” says NCDC executive director Julia Landstreet. “But new development and infrastructure are going to happen. We want to give developers and public officials the tools to assess the impacts on health before they build.”